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Corporate Compliance Conflict of Interest Disclosure Statement

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  2. Conflict of Interest Disclosure Statement Form

    MADISON COUNTY

    Conflict of Interest Disclosure Statement Form

    The Madison County Compliance Policy for Conflict of Interest includes a provision setting forth the standards of conduct expected and required of Affected Individuals to disclose all interests which could result in a conflict. 

    Please be assured that the disclosure requirements are intended to provide Madison County with a systematic and ongoing method of disclosing and ethically resolving potential conflicts of interest. Although it is impossible to list every circumstance giving rise to a possible conflict of interest, the following will serve as a guide to the types of activities that might cause conflicts and that should be fully reported.

    1. Conflict of Interest (Definition): Any situation in which financial or other personal considerations may compromise or appear to compromise (1) an Affected Individual’s business judgment; (2) delivery of services; or (3) ability for an Affected Individual to do his or her job. An actual or potential conflict of interest occurs when an Affected Individual is in a position to influence a decision that may result in a personal gain for that Affected Individual for a relative as a result of business dealings. For the purpose of this policy, a relative shall be defined as spouse, child, parent, grandparent, grandchild, sister or brother, including step and in-law relations.
    2. Outside Interests
    1. To hold, directly or indirectly, a position or a financial interest in any outside concern from which the individual has reason to believe the County secures goods or services (including the services of buying or selling stocks, bonds, or other securities), or that provides services competitive with the system).
    2. To compete, directly or indirectly with the County in the purchase or sale of property or property rights, interests, or services.
    1. Outside Activities

    To render directive, managerial, or consultative services to any outside concern that does business with, or competes with the services of the County, or to render other services in competition with the County.

    1. Inside Information

    To disclose or use information relating to the County’s business for the personal profit or advantage of the individual or his/her immediate family.

    1. Gifts, Gratuities, and Entertainment

    To accept gifts, excessive entertainment, or other favors from any outside concern that does, or is seeking to do, business with, or is a competitor of, the County – under circumstances from which it might be inferred that such action was intended to influence or possibly would influence the individual in the performance of his/her duties.

    I hereby state that I, or members of my immediate family, have the following affiliations or interest and have taken part in the following transactions that, when considered in conjunction with the position with or relation to the County, might possibly constitute a conflict of interest (check “None” or “I have no conflict of interest to report” where applicable, attach additional page as necessary):

  4. 1. Outside Interest. Identify any interests, other than investments, of yourself or your immediate family, as described in Paragraph B above. *
  8. 2. List any relatives/immediate family members currently employed by Madison County or serving as a member its Board of Supervisors. *
  12. 3. Investments. List and describe, with respect to yourself or your immediate family, all investments that might be within the category of “financial interest”, as described in Paragraph B above.*
  16. 4. Outside Activities. Identify any outside activities, of yourself or your immediate family, as described in Paragraph C above.*
  20. 5. Other Activities. List any other activities in which you or your immediate family are engaged that may be regarded as constituting a conflict of interest, giving particular attention to the Paragraphs C & D above.*
  24. 6. Gifts, Gratuities, & Entertainment. I hereby certify that neither I, nor any member of my immediate family, have accepted gifts, gratuities, nor entertainment that might influence my judgment or actions concerning the business of the County, EXCEPT as listed below.*

  28. If there are none, type "None".

  32. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your disclosure statement form will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

  40. I am a (select one):*
    43. Leave This Blank:

  45. This field is not part of the form submission.