**POLICY STATEMENT ON CONFLICTS OF INTEREST**

The Board of Trustees desires to adopt a formal policy statement
regarding conflicts of interest that may arise with respect to
individual Trustees, officers, employees and agents (collectively
referred to as \"Officials\") of \[NAME OF NETWORK\]. Maintenance of
\[NAME OF NETWORK\] good name requires that all Officials avoid not only
conduct which in fact involves a conflict of interest but also the
appearance of any such impropriety. Accordingly, a list of activities
that constitute conflicts of interest are enumerated below. This action
in no way reflects on the character or integrity of any Official, and is
instituted solely to bring \[NAME OF NETWORK\] in line with \[state\]
law.

**Section 1. [Definitions]{.underline}.** The terms used herein are
defined as follows:

**(a) Financial Interest** shall mean any interest that shall yield,
directly or indirectly, a monetary or other material benefit (other than
the duly authorized salary or compensation for his or her services to
\[NAME OF NETWORK\]) to the Official or to any Person employing or
retaining the services of the Official.

**(b) Person** shall mean any individual, corporation, partnership,
joint venture, limited liability company, limited liability partnership,
association, joint stock company, trust, unincorporated association or
any state, county or city government or agency or political subdivision
thereof other than \[NAME OF NETWORK\].

**(c) Personal Interest** shall mean any interest arising from blood or
marriage relationships or from close business or political association
whether or not any Financial Interest is involved.

**(d) Private Interests** shall mean any direct or indirect interests of
a Person in or to an organization in which \[NAME OF NETWORK\] is
affiliated.

**Section 2. [Conflicts of Interest]{.underline}.**

**(a) Financial or Personal Interest.** No Official, either on his or
her own behalf or on behalf of any other Person, shall have any
Financial Interest or Personal Interest in any business or transaction
with \[NAME OF NETWORK\] unless the Official shall first make full
disclosure of the nature and extent of such interest.

**(b) Incompatible Employment.** No Official shall engage in private
employment with, or render services for, any Person who has business
transactions with \[NAME OF NETWORK\] unless the Official shall first
make full disclosure of the nature and extent of such employment or
services.

**(c) Representing Private Interests.** No Official, whether paid or
unpaid, shall appear on behalf of any Private Interests before \[NAME OF
NETWORK\]. An Official shall not represent Private Interests in any
action or proceeding against the interests of \[NAME OF NETWORK\], nor
in any proceeding to which \[NAME OF NETWORK\] is a party.

**(d) Gifts and Favors.** No Official shall accept any gift, whether in
the form of money, thing, favor, loan or promise, that would not be
offered or given if the Official were not an Official.

**Section 3. [Disclosure and Disqualification]{.underline}**. Whenever
the performance of his or her official duties shall require any Official
to deliberate and vote on any matter involving the Official\'s Financial
Interest or Personal Interest, the Official shall disclose the nature
and extent of such interest and disqualify himself or herself from
participating in the deliberation and in the voting.

**Section 4. [Confidential Information]{.underline}.** No Official shall
disclose any confidential information acquired by him or her in the
course of his or her official duties or use such information to further
his or her Financial Interest or Personal Interests to \[NAME OF
NETWORK\]\'s disadvantage.

**Section 5. [Immediate Family]{.underline}.** The principles and intent
of this Policy Statement also apply where any member of the immediate
family of an Official is involved in any such ownership, transaction or
activity.

**Section 6. [Procedures]{.underline}**. In furtherance of this Policy
Statement, the following practices and procedures shall be observed:

**(a) Copy of Policy Statement.** A copy of this Policy Statement shall
be provided to each Official who in the judgment of \[NAME OF NETWORK\]
performs duties that could possibly be affected by any conflicts of
interest.

**(b) Certificate.** Each Official receiving a copy of this Policy
Statement shall, within two weeks thereafter, submit to \[NAME OF
NETWORK\] a certificate (on a form provided):

\(1\) that such Official has read the Policy Statement in full and has
considered his or her personal situation in light of it; and

\(2\) Either:

> \(i\) that such Official is not, to the best of his or her knowledge,
> violating any of the principles enunciated in the Policy Statement; or
>
> \(ii\) that such Official has made a full disclosure of the facts
> regarding any possible questions of violation.

**(c) Annual Review.** Each Official shall review this Policy Statement
on an annual basis and submit a new Certificate in manner and form
similar to that provided by paragraph 6(b).

\[NAME OF NETWORK\]

# **CERTIFICATE REGARDING POLICY STATEMENT**

# **ON CONFLICTS OF INTEREST**

I,
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_(please
print your name) certify that I have read the Policy Statement on
Conflicts of Interest adopted by the Board of Trustees of the \[NAME OF
NETWORK\]. I certify that I have considered my personal situation and
that:

 To the best of my knowledge, I am not violating any of the principles
enunciated in said Policy Statement.

>  Full disclosure of the facts regarding any possible question of
> violations in the principles set forth in said Policy Statement is
> provided as follows:
>
>  **I may have a Financial Interest.** \[Please describe.\]

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>  **I may have a Personal Interest.** \[Please describe.\]

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>  **I may have an Incompatible Employment situation.** \[Please
> describe.\]

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>  **Other** \[Please describe.\]

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I further certify that (1) I shall not accept any gift, whether in the
form of money, thing, favor, loan or promise, that would not be offered
or given to me otherwise, and (2) I shall not disclose any confidential
information acquired by me in the course of my official duties or use
such information to further my Financial Interest or Personal Interests
to \[NAME OF NETWORK\]\'s disadvantage.

DATED this \_\_\_\_\_\_\_\_\_ day of
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_, 20\_\_\_\_\_.

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  Signature

  Title

  Facility
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