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Conflict of Interest Attestation Form
DC Health Grants Personnel

Required fields are marked with an asterisk (*) and must be filled in to complete the form.

§ I: BASIC INFORMATION
 *
 *
 *
 *
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 *
§ II: CONFLICT OF INTEREST DISCLOSURES
Please respond to each question as it pertains to the conflict of interest (COI) categories outlined below. For each type of COI listed, a description is provided along with a YES/NO question.

If your response is "YES", then other information is requested.
If your response is "NO" - indicating no conflict of interest, then move to the next question.
COI: Beneficial Interest

You or your spouse, domestic partner, or dependent children had a beneficial interest at any point in the last calendar year in any vendor/recipient in your portfolio, including, whether held in such person's own name, in trust, or in the name of a nominee, securities, stocks, stock options, bonds, or trusts, exceeding in the aggregate $1,000, or that produced income of $200 or more? (Do not include professionally managed collective investment vehicles that pool money from many investors to purchase securities, such as mutual funds, or professionally managed retirement accounts.)
Answer the questions below:

 *
Complete the remainder of Section below
COI: Receipt of Income / Honoraria

You or your spouse, domestic partner, or dependent children received an honorarium and/or income earned for services rendered in excess of $200 from any vendor/recipient in your portfolio at any point during the last calendar year.
Answer the question below:

 *
Complete the remainder of Section below
 *
 *
COI: Outside Position w/Vendor/Recipient

You or your spouse, domestic partner, or dependent children served with any vendor/recipient in your portfolio as an officer, director, partner, employee, consultant, contractor, volunteer, or in any other formal capacity or affiliation at any point during the last three calendar years?
Answer the questions below:

 *
Complete the remainder of Section below
 *
COI: Receipt of Gifts

Have you received any gift from any vendor/recipient in your portfolio in an aggregate value of $10 or greater at any point during the most recent calendar year?

Complete the remainder of Section below
$0.00
§ III: CONFLICT OF INTEREST ATTESTATION

I understand that the making of a false statement on this form or materials submitted with this form is punishable by criminal penalties pursuant to D.C. Official Code § 22-2405 (2017). I understand that any information I give may be investigated as allowed by law or regulation. I certify that, to the best of my knowledge and belief, all of my statements are true, correct, and complete.

 *
08-03-2025
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Conflict of Interest Attestation form Submitters:
Please be aware that clicking the Submit button will prevent any further changes to this form and send an email notification to DOH Grand Management team for review.
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