Record of Conflict. The minutes of the governing board and all committees with board delegated powers shall contain:
Record of Conflict. The minutes of the governing board and all committees with board delegated powers shall contain: The names of the persons who disclosed or otherwise were found to have an actual or possible conflict of interest, the nature of the conflict of interest, any action taken to determine whether a conflict of interest was present, and the governing board's or committee's decision as to whether a conflict of interest in fact existed. The names of the persons who were present for discussions and votes relating to the transaction or arrangement that presents a possible conflict of interest, the content of the discussion, including any alternatives to the transaction or arrangement, and a record of any votes taken in connection with the proceedings. . Approved by: ##ContractorName## Name of Organization _______________________________________ Signature of Organization Official _______________________________________ Date
Record of Conflict. The minutes of the governing board and all committees with board delegated powers shall contain: The names of the persons who disclosed or otherwise were found to have an actual or possible conflict of interest, the nature of the conflict of interest, any action taken to determine whether a conflict of interest was present, and the governing board's or committee's decision as to whether a conflict of interest in fact existed. The names of the persons who were present for discussions and votes relating to the transaction or arrangement that presents a possible conflict of interest, the content of the discussion, including any alternatives to the transaction or arrangement, and a record of any votes taken in connection with the proceedings. Approved by: _______________________________________ Legal Name of Organization _______________________________________ Signature of Organization Official _______________________________________ Title of Organization Official _______________________________________ Date IRS Tax Exemption Verification Form (Annual) We, the undersigned entity, hereby testify that the 501 (c)(3) status is on file with the North Carolina Department of Health and Human Services and is still in effect. __________________________________________________________________ Name of Entity __________________________________________________________________ Signature of Chairman, Executive Director, or other authorized official ________________________________________________________ Title of above signed authorized official Sworn to and subscribed before me this ______ day of __________________, 20____ ___________________________________ Notary Signature and Seal Notary’s commission expires ____________________, 20 ___. State Certifications
Record of Conflict. The minutes of the governing board and all committees with board delegated powers shall contain: The names of the persons who disclosed or otherwise were found to have an actual or possible conflict of interest, the nature of the conflict of interest, any action taken to determine whether a conflict of interest was present, and the governing board's or committee's decision as to whether a conflict of interest in fact existed. The names of the persons who were present for discussions and votes relating to the transaction or arrangement that presents a possible conflict of interest, the content of the discussion, including any alternatives to the transaction or arrangement, and a record of any votes taken in connection with the proceedings. . Approved by: _______________________________________ Name of Organization _______________________________________ Signature of Organization Official _______________________________________ Date Conflict of Interest Verification (Annual) We, the undersigned entity, hereby testify that our Organization’s Conflict of Interest Acknowledgement and Policy adopted by the Board of Directors/Trustees or other governing body, is on file with the North Carolina Department of Health and Human Services (DHHS). If any changes are made to the Conflict of Interest Policy, we will submit a new Conflict of Interest Acknowledgment and Policy to the Department (DHHS). Name of Organization Contractor’s Authorized Agent Date Printed Name of Contractor’s Authorized Agent Title Signature of Witness Date Printed Name of Witness Title State Grant Certification – No Overdue Tax Debts Grantee/Contractor should complete this certification for all state funds received. Entity should enter appropriate data in the yellow highlighted areas. The completed and signed form should be provided to the state agency funding the grant to be attached to the contract for the grant funds. A copy of this form, along with the completed contract, should be kept by the funding agency and available for review by the Office of State Budget and Management.
Record of Conflict. The minutes of the governing board and all committees with board delegated powers shall contain: The names of the persons who disclosed or otherwise were found to have an actual or possible conflict of interest, the nature of the conflict of interest, any action taken to determine whether a conflict of interest was present, and the governing board's or committee's decision as to whether a conflict of interest in fact existed. The names of the persons who were present for discussions and votes relating to the transaction or arrangement that presents a possible conflict of interest, the content of the discussion, including any alternatives to the transaction or arrangement, and a record of any votes taken in connection with the proceedings. . Approved by: ##ContractorName## Name of Organization _______________________________________ Signature of Organization Official _______________________________________ Date CONFLICT OF INTEREST ACKNOWLEDGEMENT AND POLICY - INDIVIDUAL A conflict of interest is a situation in which the individual and/or independent contractor has competing professional or personal interests (usually in a financial or economic nature). Such competing interests can make it difficult to fulfill his or her duties and responsibilities impartially. A conflict of interest exists even if no unethical or improper act results from it. A conflict of interest can create an appearance of impropriety that can undermine confidence in the person, profession, or court system. As an independent contractor for the Department of Health and Human Services (DHHS) the contractor warrants and affirms the following: His/her business is independent and that he/she markets his/her professional services to others, except to the extent necessary to avoid a conflict of interest. The position is not used for financial gain beyond that received directly for this service nor will the work performed on this project create an appearance of a conflict of interest for me or a member of my family or others with whom I have business or other ties. When a conflict of interest is identified, the contractor will disclose it in writing to the contract administrator listed on the contract. ___________________________________________ Signature of Individual State of _________________________________ County __________________________________ I, _________________________________________, Notary Public for said County and State, certify that _____________________________________ person...
Record of Conflict. The official minutes of the Partnership Board of Directors shall reflect that the conflict of interest was disclosed, the interested Partnership Board member, officer, employee or agent did not vote on the matter, and the conflict was resolved by a vote consistent with this provision.
Record of Conflict. The official minutes of the Board of Trustees shall reflect that the conflict of interest was disclosed and the interested person(s) was (were) not present during the final discussion or vote and did not vote on the matter. Name of Organization Signature of Organization Official Date VERIFICATION OF 501 (C) (3) STATUS We, the undersigned entity, hereby testify that the undersigned entity’s 501 (c) (3) status is still in effect. Name of Agency Chairman, Executive Director, or other Authorized Official Sworn to and subscribed before me, Notary Public This the day of 20 My Commission expires: 20 (Official Seal)
