Significant Financial Interest Disclosure
(Applicable to all Sponsored Project Proposals)
Faculty/Staff Name _____________________________________________
Department ___________________________________________________
Proposal Title _________________________________________________
Proposal Submitted_____________________________________________
I am disclosing the following significant financial interests (check one) and attaching supporting documentation (in an envelope marked CONFIDENTIAL) that identifies the business enterprise or entity involved and the nature and amount of the interest:
("Significant financial interests" are defined as interest or projected annual income valued at greater that $10,000 or an equity or ownership interest of more than five percent held by an investigator and the investigator's spouse or domestic partner and dependent children. See page 1 for exempt interests.)
__ Salary or other payment for services (e.g., consulting fees or honoraria).
__ Equity interests (e.g., stocks, stock options, or other ownership interests).
__ Intellectual property rights (e.g., patents, copyrights, and royalties from such rights).
__ Other significant financial interest of the investigator that possibly could affect or be
perceived to affect the results of the research or educational activities funded or proposed for
funding.
Further I agree:
To update this disclosure during the period of the award, either on an annual basis, or as new reportable significant financial interests are obtained.
To cooperate in the development of a plan to resolve any conflicts of interest.
To comply with any conditions or restrictions imposed by the College to manage, reduce, or eliminate actual or potential conflicts of interests or to forfeit the award.
Signed: _________________________________ Date: _________________
(Original signature only - a "per" signature is not acceptable.)
Endorsements:
I have reviewed the significant financial interest disclosure and believe that it will be possible to
manage, reduce, or eliminate any actual or potential conflict of interest; and, therefore, I
recommend that proposal be submitted to the agency at the time.
Comptroller: _________________________________ Date: _____________