ࡱ> 463 bjbj 4 rr DD8p"""""$",,""AF"":,F"ppzgC W0RS#TS#FS#F,,%S#D d: CAPITAL AREA COMMUNITY ACTION AGENCY Conflict of Interest Disclosure for Fiscal Year ending September 30, 2015 Complete and return to CACAA Questions for Board Members from IRS Form 990 (New Tax Return for Non-Profit Organizations) Unless otherwise stated, these questions pertain to CACAAs tax year October 1, 2014 September 30, 2015. Please respond truthfully to these questions: Are you an independent voting member of the board? _____ Yes _____ No Did you engage in an excess benefit transaction with CACAA during this tax year? _____ Yes _____ No a. Do you have a direct business relationship with CACAA, or an indirect business relationship through ownership of more than 35% (individually or collectively), in another entity with another person who is an officer, director, trustee, independent contractor, or a key employee (Executive Director Tim Center or Head Start Director Laurie Leiner) of CACAA? Do you have a family member who has a direct or indirect business relationship with CACAA? _____ Yes _____ No Do you serve as an officer, director, trustee, key employee, partner or member of an entity that does business with CACAA? _____ Yes _____ No 4. Do you have a family relationship or a business relationship with any officer, director, trustee, or key employee of CACAA? _____Yes _____ No _____________________________________ ___________________________ Signature Date ______________________________________ Print Name Glossary: Independent voting member of governing body only if all three below were true from 10/01/13-09/30/14 -not compensated as officer or employee of CACAA including Head Start -did not receive compensation from CACAA or a related organization -neither you nor any family member (see definition below) a) was involved in an excess benefit transaction with CACAA (definition below) b) received a loan from CACAA including Head Start c) received a grant or other assistance from CACAA (including scholarships, internships, prizes or awards) d) was involved in a business transaction with CACAA Related organization CACAA does not have any related organizations Family member includes spouse; ancestors; brothers or sisters (whole or half-blood) and their spouses; children (natural or adopted); grandchildren; great grandchildren and their spouses. Excess Benefit Transaction a transaction in which you received a benefit with a value exceeding the value of the consideration received by CACAA. 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