UNIVERSITY or BOARD or TRUSTEES CONFLICT or INTEREST STATEMENT
YEAR 7/1/2016 5/30/2017

.Organization OF LOUISVILLE

Nameoflndividual Igi?akg at" 

Signature \Lw 

Business Transaction with UofL

 

1. Other than an employment relationship, do you or a family member conduct business with the UofL?
Business transactions include, but are not limited to contracts of sale, lease, license and performance
of services, whether initiated during the UofL tax year or ongoing from a prior year. Business
transactions also include joint ventures in which either the pro?ts or capital interest of the UofL and
of the interested person exceeds 10%.

if "Yes,? describe your business transactionls) with the UofL:

2. Do you or a family member own 35% of an entity (C-corporation, S-corporation, Partnership, LLC or
other entity type(s), directly or indirectly, that conducts business with the UofL?

if "Yes,? describe your business transactionis) with the UofL:

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3. Do you or a family member, in combination with other "interested person(s)" own 35% of an - 
entity (C-corporation, S-corporation, Partnership, LLC or other entity type), directly or indirectiy,
that conducts business with the UofL?
- If "Yes,? describe your business transaction(s) with the UofL:
Do you or a family member, serve as an officer, director, trustee, or key employee or an entity 

that does business with the UofL?

0 if "Yes,? describe your business transaction(s) with the UofL:

5. Do you or a family member serve as a partner, member, or shareholder of an entity (with
ownership interest in excess of 5% of a partnership or professional corporation) that conducts
basiness with the UofL?

I If "Yes,? describe your business transaction(s) with the UofL:

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6. Did a family member receive a compensation payment in excess of $10,000 from the UofL?

I if ?Yes," explain:

7. Did you or a family member receive grants or other assistance, including provision of goods,
services, or use of facilities from the UofL? Grants include scholarships, fellowships, internships,
prizes, and awards.

0 If "Yes," explain:

8. Do you have 35% control in an entity that received grants or other assistance, inciuding provision
of goods, services, or use of facilities from the UofL? 

- If "Yes," explain:

9. Do you have any loans to or from the UofL?

If "Yes,? explain.

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10. Are you aware of any excess bene?t transactions to report? An excess benefit transaction is
where the UofL directly or indirectly provided an economic bene?t where the value of the
bene?t exceeds the value of the consideration recelyed by the UofL.

- If "Yes," explain.

Business and?milv Relationships with Interested Persons

11. Do you have a family or business relationship with any other officer, director, trustee, or key 
employee of the UofL?

For each family and business relationship, identify the persons and indicate family or business
relationship.

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