Skip to content
662.841.9133
DONATE
Close
DONATE
Credit Card
Crypto
Stock
DAF
Endowment
DONATE
Credit Card
Crypto
Stock
DAF
Endowment
Volunteer
About
About Us
Board
Staff
Job Openings
Contact
Resources
United Way Help Guide
List of Funded Partners
Portals
Our Work
Early Childhood Coalition
Hunger Coalition
Health Alliance
Volunteer Northeast Mississippi
Women United
Groundswell
Back 2 School Project
ALICE
Grantmaking
Campaign
Individual
Workplace
Corporate Gifts
Small Business
About
About Us
Board
Staff
Job Openings
Contact
Resources
United Way Help Guide
List of Funded Partners
Portals
Our Work
Early Childhood Coalition
Hunger Coalition
Health Alliance
Volunteer Northeast Mississippi
Women United
Groundswell
Back 2 School Project
ALICE
Grantmaking
Campaign
Individual
Workplace
Corporate Gifts
Small Business
Code of Ethics & Conflict of Interest Agreement
Code of Ethics Policy Agreement
Electronic Signature
(Required)
By submitting this form, I confirm that I have read and reviewed the Code of Ethics on the date indicated.
Board Member Name
(Required)
First
Last
Date Signed
(Required)
MM slash DD slash YYYY
Annual Affirmation of Compliance and Disclosure Statement
At this time, I am a Board member, a committee member, or an employee of the following organizations that could be determined to have a conflict of interest.
On each line, please list the organization, your relationship to the organization, and the nature of the conflict of interest. Click the (+) symbol to add additional organizations.
Organization/Committee
Relationship to Organization
Nature of Conflict of Interest
Add
Remove
Please list any other Board members or staff members with which you have a business relationship as defined below.
A business relationship is defined as: 1. One person is employed by the other in a sole proprietorship or by an organization with which the other is associated as a trustee, director, officer, key employee, or greater-than 35% owner. 2. One person is transacting business with the other (other than in the ordinary course of either party’s business on the same terms as are generally offered to the public), directly or indirectly, in one or more contracts of sale, lease, license, loan, performance of services, or other transactions involving transfers of cash or property valued in excess of $ 10,000 in the aggregate during the organization’s tax year. 3. The two persons are each a director, trustee, officer, or greater than 10% owner in the same business or investment entity. Click the (+) symbol to add additional board/staff members.
Board or Staff Member
Relationship
Add
Remove
Please list any other Board members or staff members with which you have a family relationship as defined below.
A family relationship is defined as: Individuals serving with his or her spouse, ancestors, brothers and sisters (whether whole or half blood), children (whether natural or adopted), grandchildren, great-grandchildren, and spouses of brothers, sisters, children, grandchildren, and great-grandchildren. Click the (+) symbol to add additional board/staff members.
Board or Staff Member
Relationship
Add
Remove
Please complete the questionnaire below indicating any actual or potential conflicts of interest. If you answer “yes” to any of the questions, please provide a written description of the details of the specific action or transaction in the space allowed.
Financial Interests
– A conflict may exist where an interested party, or a family member or affiliate or an interested party, directly or indirectly benefits or profits as a result of a decision made or transaction entered into by United Way of Northeast Mississippi.
During the past 12 months, has United Way of Northeast Mississippi contracted to purchase or lease goods, services, or property from you, or from any of your family or affiliates?
(Required)
Yes
No
During the past 12 months, has United Way of Northeast Mississippi offered employment to you, or to any of your family or affiliates, other than a person who was already employed by United Way of Northeast Mississippi?
(Required)
Yes
No
During the past 12 months, have you, or have any of your family or affiliates, been provided with a gift, gratuity or favor, of a substantial nature, from a person or entity which does business, or seeks to do business, with United Way of Northeast Mississippi?
(Required)
Yes
No
During the past 12 months, have you, or any of your family or affiliates, been gratuitously provided use of the property or services of United Way of Northeast Mississippi?
(Required)
Yes
No
Other Interests
- A conflict may also exist where an interested party, or a family member or affiliate of an interested party, obtains a non-financial benefit or advantage that he would not have obtained absent his/her relationship with United Way of Northeast Mississippi, or where his/her duty or responsibility owed to United Way of Northeast Mississippi conflicts with a duty or responsibility owed to some other organization.
During the past 12 months, did you obtain preferential treatment by United Way of Northeast Mississippi for yourself, or for any of your family or affiliates?
(Required)
Yes
No
During the past 12 months, did you make use of confidential information obtained from United Way of Northeast Mississippi for your own benefit, or for the benefit of a family member or affiliate?
(Required)
Yes
No
Electronic Signature
(Required)
By submitting this form, I swear to the following:
I have received and carefully read the Conflict of Interest Policy for board members, officers, staff and certain volunteers of United Way of Northeast Mississippi and have considered not only the literal expression of the policy, but also its intent. By signing this affirmation of compliance, I hereby affirm that I understand and agree to comply with the Conflict of Interest Policy. I further understand that United Way of Northeast Mississippi is a charitable organization and that in order to maintain its federal tax exemption it must engage primarily in activities, which accomplish one or more of its tax-exempt purposes.
Except as otherwise indicated in the Disclosure Statement and attachments, if any, below, I hereby state that I do not to the best of my knowledge, have any conflict of interest that may be seen as competing with the interest of United Way of Northeast Mississippi, nor does any family member or affiliate have such an actual or potential conflict of interest.
If any situation should arise in the future which I think may involve me in a conflict of interest, I will promptly and fully disclose the circumstances to the President of the Board of Directors or to the Executive Director, as applicable.
I further certify that the information set forth in the Disclosure Statement and attachments, if any, is true and correct to the best of my knowledge, information and belief.
Board Member Name
(Required)
First
Last
Date Signed
MM slash DD slash YYYY
CAPTCHA
Phone
This field is for validation purposes and should be left unchanged.
