Grantee Conflicts of Interest Disclosure Form

ANNEX B-1

(Grantee Acronym)

(Grant #)

Grantee Conflicts of Interest Disclosure Form

The purpose of this form is to give Grantee Partners an opportunity to disclose any personal or organizational conflicts of interest as defined by section V. of Annex B, or potential for conflicts of interest.

A conflict of interest exists even if no unethical or improper act results from it. Conflicts of interest may be actual or perceived. An actual conflict of interest occurs when a decision or action would be compromised without taking immediate appropriate action to eliminate the conflict. A perceived conflict of interest is any situation in which a reasonable person would conclude that conflicting duties or loyalties exist.

The Grantee must disclose all relationships with which it or any covered person has that create, or appear to create, a conflict of interest as detailed in this Grant Agreement.

Please describe below any relationships or circumstances that could contribute to a conflict of interest. Please include the name/relationship and/or description of the conflict of interest.

1.__________________________________________________________________________

2.__________________________________________________________________________

3.__________________________________________________________________________

I hereby certify that the information set forth above is true and complete to the best of my knowledge. I agree to update this form as necessary over the course of the grant period.

Grantee Signature:_____________________________________________________________

Date: _________________________________________

IAF Approval: ____________________________________________________________

Date: _________________________________________