The Catholic University of America

 

Trustee Disclosure Statement

 

Please report below any actual, apparent or potential conflict of interest you or a family member (defined to include a spouse, child or household member) may have, including, but not limited to, any known material financial interest in or position of authority with or presumed benefit from any entity (including other religious, educational or non-profit entities) that you know to have a current or proposed transaction or business arrangement with The Catholic University of America. “Material financial interest” as used here includes any uncompensated position as a director, officer or trustee.  A financial interest is presumed to be material if it entails:

 

Any ownership or investment interest (including stock, options, a partnership interest or any other ownership or investment interest) valued at more than $10,000, except equity in a publicly traded company amounting to less than a 5% ownership interest in the company;

 

Receipt of non-dividend compensation (including salary, consulting fees, royalty payments, or other remuneration) of more than $10,000 in any 12 month period in the past 3 years, or the expectation of such compensation in the future;

 

Real property, personal property, intellectual property or any other interest valued at $10,000 or more; or

 

A position of real or apparent authority in an outside entity (including religious, educational or other non-profit entities), such as director, officer, trustee or Partner, whether or not such position is compensated.

 

 

A trustee is not deemed to have a material financial interest in a publicly-traded entity by reason of an investment in that entity by another publicly-traded entity, such as through a mutual fund, of which the trustee does not control investment decisions. Each trustee has an ongoing obligation to notify the Board promptly of any actual, apparent or potential conflict of interest as it arises.

 

I have received and read a copy of The Catholic University of America Board of Trustees Conflict of Interest Policy. I affirm that, other than the interests reported on the attached questionnaire, I am aware of no actual, apparent or potential conflict of interest (including known interests of family members), including no known material financial interest within the meaning of the Conflict of Interest Policy in any entity that I know to have a current or proposed transaction or business arrangement with Catholic University.

  

 

 

                                                              QUESTIONNAIRE

 

1.         Are you an officer, director, employee, trustee, advisor or consultant of any corporation, company, firm or other business enterprise with which The Catholic University of America has business dealings?

 

[  ] YES                       [  ] NO

 

If YES, please list below, the names of such entities, the office held and the approximate dollar amount of business with CUA during the last twelve months.

 

 

 

 

 

 

 

2.         Are you an officer, employee, trustee, director, advisor or otherwise connected with any religious, educational or other non-profit entity other than The Catholic University of America?

 

 

[  ] YES                       [  ] NO

 

If YES, please list below the names of such institutions and your relationship:

 

 

3.         Do you, or does any member of your family, have a material financial interest in (a material interest is defined as an ownership interest of 5% or more) or receive remuneration or income from, any business organization with which The Catholic University of America has business dealings?

 

 

[  ] YES                       [  ] NO

 

If YES, please supply the following information:

 

a.       Names of the entity in which such interest is held and the person by whom it is held.

 

 

b.   The nature of such financial interest.

 

 

 

 

4.         Did you, or any member of your family, receive during the last twelve months, any gifts from any source from which The Catholic University of America buys goods or services or with which the University has significant dealings?

 

 

[  ] YES                       [  ] NO

 

If YES, please list.

 

 

 

 

 

Trustee: _________________________________________________________________

(Print Name)

Date: _________________ Signed: ______________________________________