This form is the “Shield” for your Foundation. It ensures that every decision made by the Advisory Board is beyond reproach and that no personal interests interfere with the fair distribution of funds.
🛡️ Conflict of Interest Disclosure Form
Jackie Kallen Foundation: Advisory Board
Reviewer Name: ___________________________
Review Cycle: [e.g., 2026-2027]
Date: _________________
1. Purpose
As an Advisory Board member, you have a duty of loyalty to the Jackie Kallen Foundation. A conflict of interest arises when your personal, professional, or financial interests (or those of a family member) could potentially influence your evaluation of a grant application.
2. Disclosure Questionnaire
Please answer “Yes” or “No” to the following:
- Do you or an immediate family member serve as a director, officer, employee, or consultant for any organization applying for a grant this cycle?
- [ ] Yes [ ] No
- Do you or an immediate family member have a financial interest (e.g., ownership, investment) in any entity applying for funding?
- [ ] Yes [ ] No
- Have you received any gifts, loans, or services from an applicant within the past 12 months?
- [ ] Yes [ ] No
- Are you aware of any other relationship (friendship, professional partnership, etc.) that may create a perceived bias in your evaluation of a specific applicant?
- [ ] Yes [ ] No
3. Details of Potential Conflict
If you answered “Yes” to any of the above, please provide the name of the organization and the nature of the relationship below:
Organization Name: ________________________________________________
Nature of Conflict: ________________________________________________
4. Certification & Recusal Agreement
By signing below, I certify that the information provided is true and complete to the best of my knowledge. I agree to:
- Recuse myself from the scoring and discussion of any applicant where a conflict exists.
- Maintain the confidentiality of all application materials and board deliberations.
- Uphold the “Championship Standard” of the Jackie Kallen Foundation.
Signature: ____________________________________ Date: __________
The Chairperson’s Role in Conflicts
As Chairperson, your job is to collect these forms before the scoring begins in January. If a member discloses a conflict, you simply:
- Remove that specific application from their review packet.
- Ask them to leave the room (or the Zoom call) when that specific applicant is being discussed for a final vote.
- Note the recusal in your Consolidation Summary for the Board of Directors to show you followed the rules.