Annual conflict of interest disclosure

[Land trust name] conflict of interest disclosure for [Year covered]

Name: [Your name]. Role: [Board member, staff or volunteer]. Please return this form to [Name and title]. Land trusts make decisions about land, money and relationships in their own communities, so conflicts are common and normal. What matters is that they are disclosed and handled openly.

1. Policy acknowledgment

• I have read the conflict of interest policy of [Land trust name].
• I understand I must disclose a conflict as soon as it comes up, not only on this form.
• I understand I must leave the discussion and vote on any matter where I have a conflict.

2. Land and easement interests

List any land you, your family or a business you are part of owns or plans to buy that is on or next to land [Land trust name] protects or is talking about protecting.

3. Business and money interests

List any business, job, contract or payment that involves [Land trust name], a landowner it works with, or a vendor it pays, such as surveyors, appraisers, attorneys, contractors or real estate agents.

4. Other roles

List boards, committees or public offices you serve on that may deal with [Land trust name], such as a planning board, another land trust or a funding agency.

5. Gifts

List any gift, favor or hospitality worth more than a token amount that you received from someone doing business with [Land trust name] this year.

6. How disclosures are handled

The board chair or a committee the board names reviews completed forms each year. A disclosed interest does not mean anyone did something wrong. It means the person steps out of the discussion and vote on that matter, and the minutes record that they did. Completed forms are kept with the board records.

7. Statement

• I have nothing to disclose this year.
• My disclosures are listed above, with more detail attached if needed.

The information on this form is true and complete to the best of my knowledge. I will update it if anything changes during the year.