Jehovah Saints Homeless Shelters

Annual Disclosure Form

Conflict of Interest and Ethical Responsibility Statement

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Purpose

As a tax-exempt nonprofit organization, Jehovah Saints Homeless Shelters is committed to maintaining the highest standards of integrity, transparency, and accountability. To ensure compliance with federal and state laws, as well as the organization’s bylaws, all board members, officers, and key personnel are required to disclose any actual, perceived, or potential conflicts of interest annually.

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Part 1: Personal Information

Name: ___________________________________________

Position/Role: ____________________________________

Date: ___________________________________________

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Part 2: Conflict of Interest Policy Acknowledgment

I acknowledge that I have received, read, and understand the Conflict of Interest Policy for Jehovah Saints Homeless Shelters. I agree to comply with its terms and to disclose any financial, personal, or professional interests that may create a conflict of interest with my duties to the organization.

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Part 3: Conflict of Interest Disclosure

Please answer the following questions to the best of your knowledge:

• Do you, or any of your immediate family members, have a financial interest in any entity (e.g., business, vendor, or contractor) that does or seeks to do business with Jehovah Saints Homeless Shelters?

  • ☐ Yes

  • ☐ No
    If yes, please describe:

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• Do you, or any of your immediate family members, serve as an officer, director, trustee, partner, employee, or consultant for any entity that does or seeks to do business with Jehovah Saints Homeless Shelters?

  • ☐ Yes

  • ☐ No
    If yes, please describe:

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• Have you received, or do you anticipate receiving, any gifts, favors, or other benefits from any entity or individual that does or seeks to do business with Jehovah Saints Homeless Shelters?

  • ☐ Yes

  • ☐ No
    If yes, please describe:

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• Do you have any other relationships, commitments, or activities that could create a conflict of interest or the appearance of a conflict of interest with Jehovah Saints Homeless Shelters?

  • ☐ Yes

  • ☐ No
    If yes, please describe:

  • _______________________________________________________

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Part 4: Certification

I certify that the information provided in this disclosure form is true and complete to the best of my knowledge. I agree to update this disclosure promptly if any changes occur that could create a conflict of interest. I understand that failure to disclose a conflict of interest may result in disciplinary action, including removal from my position with Jehovah Saints Homeless Shelters.

Signature: ___________________________________________

Date: _______________________________________________

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For Internal Use Only

Reviewed by: ________________________________________

Date of Review: ______________________________________

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Action Taken (if any):

 

Instructions for Use:

• Distribute this form to all board members, officers, and key personnel at the beginning of each fiscal year.

• Collect completed forms and review them during a board meeting or by a designated committee (e.g., Governance Committee).

• Retain completed forms in the organization’s records for at least 3 years for auditing and compliance purposes.

• If any conflicts of interest are disclosed, document how they are managed or resolved to ensure compliance with the organization's policies.

 

This Annual Disclosure Form is a vital tool for maintaining transparency, accountability, and ethical governance within Jehovah Saints Homeless Shelters.