Collaborative Conflict of Interest Form

Maricopa Regional Continuum of Care
Conflict of Interest Disclosure Statement
Continuum of Care Board and Collaborative Members

In accordance with the provisions of 24 CFR 578.95, each member of a Continuum of Care ("CoC") Collaborative shall affirm that they have read and acknowledge that they are to avoid conflicts of interest in their actions and service on the CoC. It is expected that all CoC members will use good judgment, adhere to high ethical standards, and avoid situations that create an actual or perceived conflict of interest.

As a member of a CoC collaborative, you acknowledge the following (please acknowledge by checking the box):
If the organization I represent receives funds or benefits from the CoC, I agree not to participate in the decision-making process, deliberations or gain inside information that would benefit the organization that is unavailable to other organizations, with regards to obtaining funds or benefits, unless the actions fall under an exception listed in 24 CFR 578.95(d)(2).
I Agree
If I am unable to render impartial assistance in the provision of any type or amount of financial assistance or be objective in performing work with respect to the CoC, I will recuse myself from those activities, which may include removing myself from a meeting, discussion and/or deliberation if requested.
I Agree
If the organization I represent receives funds or benefits from the CoC, I agree not to participate in the decision-making process, deliberations or gain inside information that would benefit the organization that is unavailable to other organizations, with regards to obtaining funds or benefits, unless the actions fall under an exception listed in 24 CFR 578.95(d)(2).
I Agree
If the organization I represent receives funds or benefits from the CoC, I agree that I have a conflict of interest. This conflict does not exist if it is subject to an exemption listed in 24 CFR 578.95(d)(2).
I Agree
If I, or someone in my immediate family or business ties, may obtain a financial interest or benefit from the award of funds or benefits and/or if I, or someone in my immediate family or business ties, have a financial interest in any contract, subcontract or agreement with respect to funded activities and/or if I, or someone in my immediate family or business ties, have a financial interest in the proceeds derived from a funded activity, I agree that I have a conflict of interest. This conflict provision applies to my time as a member of a CoC collaborative and during the one-year period following my tenure. This conflict does not exist if it is subject to an exemption listed in 24 CFR 578.95(d)(2).
I Agree
If I am on a CoC collaborative, I agree to exercise my duties to that collaborative in good faith, in a manner that is in the best interests of the CoC, and with such care, including reasonable inquiry, as an ordinarily prudent person in a like position would use under similar circumstances.
I Agree
To further the goals of the community, I agree to support the principles and strategic goals adopted by CoC Board and Collaborative.
I Agree
To fully disclose possible conflicts of interest, I hereby disclose that I have a financial or other interest (such as your current employment or a seat on a Board of Directors, for example) of the following non-profit and/or for-profit organizations: (please include the organization you represent, if applicable.)
I hereby certify that the foregoing is true and correct to the best of my knowledge.
I Agree
Collaborative Member Name:
Email:
Organization:

Collaborative Conflict of Interest Form

Maricopa Regional Continuum of Care Conflict of Interest Disclosure Statement Continuum of Care Board and Collaborative Members

Maricopa Regional Continuum of Care
Conflict of Interest Disclosure Statement
Continuum of Care Board and Collaborative Members