Disclosure of Direct or Indirect Financial Interest

Pursuant to "Conflicts of Interest" Policy 3720, UBP employees and all vendors or other contractors with the University must disclose, using this form, any direct or indirect financial interest a University employee may have in a proposed contract or other business transaction with the University. In addition, any individual or business entity proposing to enter into a contract or other business transaction with UNM in an amount of $20,000 or greater must complete and sign this form whether or not a University employee has a direct or indirect financial interest.

To the best of your knowledge, does any present employee of UNM, or person who was employed by UNM within the last 12 months, have any direct or indirect financial interest in the contract or other business transaction that is proposed with UNM? ________ (yes or no)

For the purposes of this policy, "financial interest" includes 1) any direct or indirect financial interest; 2) any transaction between the University and the employee or a member of the employee's immediate family (immediate family includes the employee's spouse, domestic partner, brother, sister, parent, child, or in-law); or 3) any transaction between the University and a business entity (business entity means corporation, sole proprietorship, partnership, LLC, or similar entity) if the employee or a member of the employee's immediate family meets one or more of the five criteria listed below:

1. has an ownership interest (other than as owner of less than one percent (1%) of the stock of a publicly traded corporation) in the business entity of a University vendor or contractor;

2. is an employee, partner, officer, director, trustee, or paid consultant to such business entity;

3. has received grant support or benefited from a donation from such business entity (when a procurement is being proposed refer to Section 5.3. herein for additional information);

4. has received support for travel expenses, honoraria, or similar forms of remuneration from such business entity; or

5. has a right to receive royalties from such business entity.

If the answer to the question above is "yes", please answer the following questions:

Name of UNM employee: _____________________________ present or former? (circle one)

Present or former UNM employee's department: _________________________________

Relationship to contractor or contractor's owner, officer or employee: ___________________________

Did the present or former UNM employee participate directly or indirectly in the University's decisions with respect to this proposed transaction (such as by influencing the decision to enter into the transaction, helping to prepare the specifications, or having input or influence in deciding to whom the contract is awarded)? _______ (yes or no) If yes, please explain:

If the UNM employee's financial interest is through a member of the employee's immediate family, please give the family member's name, title and business address:

Will the family member be involved in carrying out the proposed contract with UNM? _____________
If the answer is "yes", please attach a sheet describing the family member's role in the proposed contract.

I certify that the answers to the foregoing questions are true to the best of my knowledge.

Name: __________________________________ Title: _______________________ Date: __________

Comments may be sent to UBPPM@UNM.edu
http://www.unm.edu/~ubppm

Return to "Conflicts of Interest" Policy 3720, UBP