___ Public Servant
CONFLICT OF INTEREST DISCLOSURE STATEMENT
Pursuant to and in compliance with Indiana Code 35-44.1-1-4
(Form adapted for use by Indiana University)
___ Campus Exec or VP
___ General Counsel
___ Trustees’ Office
1. Name of public servant submitting statement:
2. Title or position with Indiana University:
3. Home campus:
4. This statement is submitted (check one):
As an annual disclosure statement of my financial interest connected with any contracts or
purchases of Indiana University, which are made on a regular basis with or from particular
contractors or vendors; or
As a single-transaction disclosure statement of my financial interest in a specific contract or
purchase connected with Indiana University proposed to be made by Indiana University with or
from a particular contractor or vendor.
The phrase “my financial interest,” as used in this disclosure statement includes any interest of
myself, my spouse, or my dependent(s).
5. Name(s) of contractor(s) or vendor(s):
6. Description of contract(s) or purchase(s) to be made by Indiana University: (Describe the kind of
contract involved, names of parties involved [other than those disclosed above], the effective date and
term of contract or transaction date of purchase if reasonably determinable. [Dates required if this is
a single-transaction disclosure.])
7. Description of my financial interest: (Describe in what manner you or your family expects to derive a
profit or financial benefit from, or otherwise has a pecuniary interest in, the above contract(s) or
purchase(s). State the approximate dollar value of such profit or benefit.)
(Attach extra pages if additional space is needed.)
8. Affirmation of Public Servant: I affirm, under penalty of perjury, the truth and completeness of the
statements made above, and that I am the public servant named above.
(Signature of Public Servant)
(Dean, Department Chair or Director)
(Campus Executive Officer or Vice President)
(Vice President & General Counsel)
A copy of this disclosure statement must be submitted to the Secretary of the Board of Trustees, prior to
final action being taken on the purchase or contract.
Within 15 days following final action being taken on the purchase or contract, a copy of this statement
must be filed electronically by the Secretary of the Trustees of IU with the State Board of Accounts.
Approval of The Trustees of Indiana University: I, Secretary of the Trustees of Indiana
University, which employs the above named public servant, hereby report that the Board of
Trustees of Indiana University approved the participation of the public servant in the above
described contract(s) or purchase(s).
(Secretary, The Trustees of Indiana University)
Date submitteded to State Board of Accounts
Date of Board Meeting