Director and Officer

Annual Conflict of Interest Statement

Name: _________________________________ Date: __________

Position:

Are you a voting director? Yes ____ No ____

Are you an officer? Yes ____ No ____

If you are an officer, which position do you hold: _____________________________________

I affirm the following:

I have received a copy of the Rotary Club of Gainesville Goundation Conflict of interest policy. ____ (initial)

I have read and understand the policy. ____ (initial)

I agree to comply with the policy. ____ (initial)

I understand that RCGF is charitable and in order to maintain its federal tax exemption

it must engage primarily in activities which accomplish one or more of its tax-exempt

purposes. ____ (initial)

Disclosures:

a. Do you have a financial interest (current or potential), including a compensation

Arrangement, as defined in the Conflict of Interest policy with RCGF? ___ Yes ____ No

If yes, please describe it: _________________________________________________

If yes, has the financial interest been disclosed, as provided in the Conflict of

Interest policy? ____ Yes ____ No

b. In the past, have you had a financial interest, including a compensation arrangement,

as defined in the Conflict of Interest policy with RCGF? ____ Yes ____ No

If yes, please describe it, including when (approximately):

____________________________________________________________

If yes, has the financial interest been disclosed, as provided in the Conflict of

Interest policy? ____ Yes ____ No

Are you an interested director, as defined in the Conflict of Interest policy? ____ Yes ____ No

_____________________________________ Date: ___________________

Signature of director

Date of review by the Conflict of Interest Committee: _____________