Conflict of Interest Disclosure Statement

To view the current Conflict of Interest Policy, please click here

1. Do you or a Relative have any organizations or businesses where you serve in a fiduciary role (e.g., officer, Director, Committee Member, elected or appointed official, owner) and where the organization's interests may compete or otherwise be in conflict with the interests of the Corporation? And/or, do you or your Relative, have any organizations where you play a leadership role, and where the organization's interests or philosophy may be contrary to the interests or philosophy of the Corporation? *

Note: Members of religious congregations who serve on multiple Catholic Charities of the Diocese of Rochester Boards or who have multiple leadership roles within Catholic Charities of the Diocese of Rochester need not disclose those relationships because it is reasonable to assume a unity of mission throughout Catholic Charities of the Diocese of Rochester entities.

2. Have you or your Relative (or any business entity related to you or your Relative) held any direct and/or indirect Financial Interests within the past 5 years? *

3. Are there any individuals that are either your Relatives, or with whom you have a Close Personal Relationship, that you supervise (directly or indirectly) in the Corporation and/or that may serve on the Board of Directors? *

4. Have you received any substantial gifts, gratuities, favors or entertainment, or has your Relative or any entity related to you or your Relative received any substantial gifts, gratuities, favors or entertainment in the last year that might reasonably be perceived as being given to influence you in the performance of your duties on behalf of the Corporation. *

NOTE: It is not necessary to report gifts, favors or entertainment whose value is less than $100.

5. Do you or a Relative have any other Outside Interests or Outside Activities that could compromise, or appear to compromise, your fiduciary duty of loyalty to the Corporation. *

6. Have you ever been found guilty after trial, or pleaded guilty, not contest or nolo contendere to a crime (felony or misdemeanor) involving fraud, breach of fiduciary duty or theft, in any court in the past 7 years. And/or, are there any such criminal charges pending against you in any court? *

7. Please provide an explanation, including the dates, which court, the charge and the outcome.

8. Have you ever been convicted of a criminal offense related to the provision of health care items or services? *

9. Please provide an explanation, including the dates, which court, the charge and the outcome. (copy)

10. Are you currently, or have you ever been, debarred, suspended, excluded or otherwise ineligible to participate in any Federal or State healthcare program? *

11. Pursuant to the Camp Stella Maris policy on Conflicts of Interest and Related Party Transactions, I hereby certify the following: *

I am an employee with Substantial Influence, Board Member or Committee Member of Camp Stella Maris or one of its regional and/or special services agencies;
I have received, read and understand the Conflict of Interest and Related Party Transactions policy and operating definitions and agree to comply with my obligations under the policy;
I agree to maintain the confidentiality of all matters which are sensitive or proprietary relating to the Corporation or any of its affiliates;
I understand that Camp Stella Maris in order to maintain their federal tax exemption, must engage primarily in activities that are charitable in nature and accomplish one or more of their tax-exempt purposes;
On an ongoing basis, I agree to disclose any potential Conflict of Interest that may arise in the course of my official duties on behalf of the Corporation;
agree to provide all necessary information to enable the Corporation to determine the Materiality of a potential Conflict of Interest. I also agree to assist the Corporation to resolve any potential conflicts.

By entering my digital signature, I acknowledge that the information provided is true and correct to the best of my knowledge. *

Name *

First

Last

Please provide the best phone number to reach you in the event that the Compliance Officer Office needs to discuss any of your responses. *

585-346-2243
4395 East Lake Road
Livonia, NY 14487

Camp Stella Maris of Livonia, Inc. is a registered 501(c)(3). EIN: 16-0743941