Do you, your spouse, domestic partner, dependent child or member of household have any association with the RF, State University of New York (SUNY), or any organization that does business with the RF? No Yes, please detail below: Name Organization Address Position Description List the name of warrants, stocks, securities and other investment interests, including any interests in limited or general partnerships owned by you, your spouse, or your dependent children at time of filing. List only the interests which amount to an ownership interest of greater than 15%. DO NOT LIST AMOUNTS. Self/Spouse/Domestic Partner Issuing Entity Dependent Children Do you or your spouse, domestic partner, dependent child or member of household have any Financial or Other Interest that you believe may be relevant to or in conflict with the exercise of your duties on behalf of the RF? If so, please detail below: Investigator Certification: I have read and understood the Conflict of Interest Policy. I agree to file a new or updated Investigator Disclosure Form if the answer to any of the above questions changes. I certify that the above information is true and correct to the best of my knowledge and that I have read and agree to be bound by SUNY Potsdam’s Conflict of Interest Policy. I further certify that I will advise SUNY Potsdam upon any material change in circumstance that may occur. Signature: Date:
Do you, your spouse, domestic partner, dependent child or member of household have any association with the RF, State University of New York (SUNY), or any organization that does business with the RF? No Yes, please detail below: Name Organization Address Position Description List the name of warrants, stocks, securities and other investment interests, including any interests in limited or general partnerships owned by you, your spouse, or your dependent children at time of filing. List only the interests which amount to an ownership interest of greater than 15%. DO NOT LIST AMOUNTS. Self/Spouse/Domestic Partner Dependent Children Issuing Entity Do you or your spouse, domestic partner, dependent child or member of household have any Financial or Other Interest that you believe may be relevant to or in conflict with the exercise of your duties on behalf of the RF? If so, please detail below: Investigator Certification: I have read and understood the Conflict of Interest Policy. I agree to file a new or updated Investigator Disclosure Form if the answer to any of the above questions changes. I certify that the above information is true and correct to the best of my knowledge and that I have read and agree to be bound by SUNY Potsdam’s Conflict of Interest Policy. I further certify that I will advise SUNY Potsdam upon any material change in circumstance that may occur. Signature: Date:
COIAnnualDisclosure.docx