Conflict of Interest Annual Questionnaire
Not legal advice. This questionnaire supports disclosure. It is not a D&O insurance product and does not bind coverage.
Organization: ______________________ Year: __________
Director name: ______________________ Role: __________
Questions
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List entities (employer, client, vendor, landlord, nonprofit, family business) where you are an owner, director, officer, employee, or material advisor.
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List any transaction in the last 12 months between the board’s organization and an entity above (or a family member’s entity).
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List any upcoming matter you expect will create a conflict at this board.
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Do you receive compensation from the organization other than standard director stipends or expense reimbursement? If yes, describe.
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Is there any other interest a reasonable director would expect you to disclose?
Attestation
I have answered completely to the best of my knowledge. I will update this disclosure when a new conflict arises.
Signature: ______________________ Date: __________
Board use only
| Field | Entry |
|---|---|
| Received by | |
| Date filed | |
| Follow-up needed? | |
| Related decision / recusal IDs |
See it in Prepared Board
Prepared Board tracks conflict-of-interest attestations and disclosed conflicts on decisions. On Northlight Robotics, Gwen Park’s Tidewater conflict is disclosed on the live Series B item. Sign in as a sample board (see /sample-decision) (password on /facts), pack /pack/demo-pack-northlight-q4, or pick a board at Try a board.
For a closed recusal on the decision record, walk Piscataqua Harbor Trust (Spruce Creek / Caleb Whitmore) via Try a board or a sample board (see /sample-decision) — pack /pack/demo-pack-piscataqua-fall.
Related practice
- How-to: How to handle a director recusal
- Thought leadership: Conflict of interest is part of the decision record
- Printable companion: Recusal record template
Prepared does not quote, bind, or store a live D&O policy. Limits: /facts · /agent-facts.json.