Conflict of Interest Disclosure Questionnaire


Answers should cover the previous calendar year and the current year-to-date. If additional space is necessary to fully describe the details of your answer to any question, please provide such explanation via an attachment. Once complete, email signed Questionnaires to [email protected].

  1. In the past year, have you or any of your affiliated persons provided services or property to the Los Angeles LGBT Center (“Center”) for which compensation was received? (“Compensation” excludes salary received from the Center.)



  2. In the past year, have you or any of your affiliated persons purchased services or property from the Center (excluding purchases made in connection with fundraising events such as silent or live auction items)?

     


  3. In the past year, have you or any of your affiliated persons derived any personal profit or financial gain by reason of your association with the Center?

     


    If you answered yes to any of the above questions (1-3), please specifically describe the nature of the services or property provided and/or purchased and the amount of compensation and/or purchase price and/or the nature of the personal profit or financial gain you received and from whom (please provide this information for each instance; if more room is needed to provide the required details, continue on back or include an attachment). For example: Acme Drugs: $400 (2 lunches per month and 4 total dinners); RoadRunner Rx: $150 (1 lunch per month and 1 reference book):



  4. Please indicate whether you or any of your affiliated persons had, have or will have any direct or indirect interest in any business transaction(s) in the past calendar year or in the current calendar year to which the Center was, is or will be a party.

     


    If yes, please describe the transaction(s) and the date(s) they did or will occur:

     

  5. Did you or any of your affiliated persons have a direct or indirect business relationship with the Center (including through ownership of more than 10% in another entity doing business with the Center, whether such ownership is individual or collective with other Center current officers, directors and/or key employees and former officers, directors and/or key employees)?

     


    (5 Continued) If yes, please describe the relationship(s), including names of the entity and other current or former Center officers, directors and/or key employees involved. Also, please state the percentage ownership held by you and/or your affiliated persons, or other Center current officers, directors and/or key employees and former officers, directors and/or key employees, individually or collectively:

     

  6. Were you or any of your affiliated persons indebted to pay money to the Center at any time during the past calendar year (other than, for example, travel advances)? NOTE: Charitable pledges are not considered indebtedness for purposes of this questionnaire.

     


    If yes, please describe the indebtedness:

     

  7. Did you have a family relationship or a business relationship with any other officer, director, trustee or key employee? NOTE: For purposes of this question, a “business relationship” does not include a relationship between an attorney and client, a medical professional and patient or a priest/clergy and penitent/communicant.

     


    If yes, please identify the name(s) of the individual(s) and the nature of the family or business relationship:

     

    If yes, did the business involve transfers of cash or property valued in excess of $10,000 in the aggregate during the past year?



  8. Have you served as an officer, director, trustee, key employee, partner or member of an entity (or shareholder of a professional corporation) doing business with the Center?

     


    If yes, please name the entity and describe your role:

     

  9. In the past year, did you or any of your affiliated persons receive, or become entitled to receive, directly or indirectly, any benefits from or as a result of your relationship with the Center that in the aggregate would be valued in excess of $100 (in the case of key employees this excludes salary and benefits paid directly by the Center)?

     


    If yes, for each instance, please specifically identify the source, value and nature of the benefits received or accrued (see Question 1 for example of information required):

     

  10. Are you or any of your affiliated persons a party to or have an interest in any pending legal proceeding involving the Center?

     


    If yes, please describe the proceeding(s):

     

  11. Are you aware of any other events, transactions, arrangements or other situations that might constitute a real or apparent conflict of interest on your part or that of your affiliated persons or that you believe should be examined by the Co-Directors of Health Services (“Co- Directors”) in accordance with the terms and intent of the Center’s conflict of interest policy?

     


    If yes, please specifically describe the events, transactions, arrangements and/or situations:

     

I hereby confirm that I have read and understand and agree to comply with the Center’s Conflict of Interest Policy and that my responses to the Conflict of Interest Disclosure Questionnaire are complete and correct to the best of my knowledge and belief. I further confirm that in the event I become aware of any actual or apparent conflict of interest involving myself or any of my affiliated persons that I will immediately disclose the details of such situation to the Co-Directors

ELECTRONIC DISCLOSURE AND CONSENT. The delivery of my signature by facsimile or email transmission (including .pdf or any electronic signature complying with the U.S. federal ESIGN Act of 2000, e.g. WP E-Signature by ApproveMe, LLC) that includes a copy of my signature is as effective as signing and delivering this agreement in person.  By signing I agree to the electronic signing and delivery of this agreement.

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Document name: Conflict of Interest Disclosure Questionnaire
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April 12, 2024 10:41 am PDTConflict of Interest Disclosure Questionnaire Uploaded by Daniel Garcia - [email protected] IP 12.35.137.10
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