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Financial Disclosure Statement

Financial Disclosure Statement - Federal Project

Financial Disclosure Statement
Federal Project
Investigator _____________________________________________ Department __________________________________
Federal Agency _________________________________ Dates of Federal Project _________________________________
Federal Project Title __________________________________________________________________________________
The investigator is required to complete this disclosure statement and submit it to Contract and Grants or the Comptroller
with each proposal for new or renewed federal support. Refer to the Central New Mexico Community College (CNM)
Administrative Directive, "Conflict of Interest Under Federal Projects," for definition of terms or procedural explanations.
If "yes" is given as a response to any of the questions, please describe in detail on the back of this form, any interests
that could affect the work performed or to be performed under this federal project. If you are not an employee of
CNM, substitute the name of your employer for CNM in these questions.
Please circle the response that represents your personal circumstances:
YES NO 1. Do you and/or family members have a financial interest that together is more than $10,000 in value
or 5% of a company's equity (whichever is less) that reasonably appears to be affected by the work
performed under this federal project?
YES NO 2. Do you and/or your family members expect to receive, in the next twelve months, salary, royalties, or
other payments from entities other than CNM, that will together exceed $10,000, and that reasonably
appear to be affected by the work performed under this federal project?
YES NO 3. Do you hold a position as a director, officer, partner, trustee, employee, or any position in management
of an entity other than CNM that reasonably appear to be affected by the work performed under this
federal project?
YES NO 4. Do you have any agreement with any party other than the federal agency that would grant that
party access to the work that you are performing under the federal project or that could affect any
confidentiality requirement of this project?
YES NO 5. Do you have any agreement with any party for financial benefits that result from work you are
performing or will perform under this federal project?
YES NO 6. Do you have any interests or employment outside CNM that could affect your ability to
perform work as required by this federal project?
YES NO 7. Do you have a consulting agreement with any party, other than the federal agency or CNM, that
is related to any work performed or to be performed under this federal project?
YES NO 8. Are you aware of any potential or actual conflicts of interest in connection with your participation
in this federal project?
By signing and submitting this Financial Disclosure Statement to the Contract and Grants Manager or the Comptroller,
I hereby certify to CNM as follows:
a. Except as answered above, and detailed on the back of this form, I know of no other potential or actual conflicts of interest
in connection with my participation in the federal project identified above;
b. I have received a copy of the CNM administrative directive, " Conflict of Interest Under Federal Projects,' and have
read and understand the concepts and processes discussed in that document;
c. I have been informed of, and agree to comply with, my reporting responsibilities as stated in the CNM administrative directive,
Conflict of Interest under Federal Projects;
d. I have been informed of any conflict of interest regulations adopted by the federal agency; and
e. If, during the term of the federal project identified above (including any renewal periods), I become aware of any information
that would cause me either to change my answer to any questions I previously answered "NO to "YES" or supplement my
answer to any question I previously answered "YES", I will within 30 days of becoming aware of that information, submit to
the Contract and Grants Manager or the Comptroller an updated Financial Disclosure Statement disclosing such information.
____________________________________________________________________ ________________________
Signature of Investigator Date
__________________________________________________________________________________________________
Name of Employer Financial Disclosure Statement Addendum
Federal Project
The investigator is required to complete this disclosure addendum, if "YES" was the response to any
question on the Financial Disclosure Statement. Provide as much information as possible in detailing
the information on which your answer is based.