commcr or QUESTIONNAIRE
FISCAL YEAR 7/1/2016 - else/201?

Printed Name: 3 Elm?) 

 

Check all covered companies
and note average hours spent
WEE per week.
. 
UofL Foundation 

. .
UofL Housing 

University Holdings; inc.


. l"
The Nacleus Real.
Properties, Inc. (TNRP)

. l?
UofL Real Estate
Foundation, inlc. (ULREF)


Pediatric Medical Office
- Build-Engine. (PMOB) .

r? .
Louisville Medical

Center Development
Corporation 

Other Entit?s):

Average
hours per
week:



Page 1 of 5

ULF-OO7284 

 

CONFLICT OF INTEREST QUESTIONNAIRE
FISCAL YEAR ?/1/2016 .. 

Printed Name:

 

When used below, the term "affiliated persons" include the following:
yourspouse, domestic partner, child, mother, father, oi?
any corporation or organization of which you are a board

member, an officer, ,a partner, participate in management or are
employed by,'or are directly or indirectly, a debt holder or the 
beneficial owner of any class of equity securities; and any trust or
other estate in which you have a substantial beneficial interest or as to
'whichyou serve as a trustee or in a similar capacity.

When used below, the term ?businesstransactions" include, but are not
limited to, contracts of sale, lease, license and performance of services,
whether initiated during a Covered Com pany's tax year or ongoing from
a prior year. Business transactions also include joint ventures in which
either the profits or capital intereSt of the organization and of the
interested person exceeds 10%. 

Business Transactions with Organization .


1) Do you or an affiliated person conduct business with an
organization?

if "Yes,?describe your business transaction(s) with the organization

and, specify which one if you checked multiple organization(s) aboveaffiliated person own 35% of an entity (C-corporation, .
rtnership, LLC or other entity type), directly or
indirectly, that conducts business with an organization?

if "Yes," describe your business transaction(s) with the organization
and, specify which one if you checked multiple organizationis) above:

 

 

 

Page 2 of5 - ULF-OO7285

 

 OF QUESTIONNAIRE
FISCAL YEAR 71112016 - 6/ 30/ 2017?

Printed Name:

 

3) Do you or an affiliated person, in combination with other affiliated
person(s)" own 35% of an entity (CI?corporation, S?corporation,
Partnership, LLC or other entity type), directly or indirectly, that 
conducts business with an organization? I

. If "Yes,?I describe your business transactionls) with the organization
and, specify which one if you checked. multiple organization(s) above: 

Do you or an affiliated person, serve as an officer, director, trustee,
- or key employee, of an entity that does business with an organization?

If "Yes," describe your business transaction(s) with the organization
and, specify which one if you checked multiple organizationis) above:

5) Do you or an affiliated person serve as a partner, member, or
shareholder of an entity (with ownership interest in Excess of 5% ofa
partnership or professional corporation) that conducts business with an

organization?

If ?Yes," describe your business transaction(s) with the organization 
and, Specify which one if you checked multiple organizationls) above: 

6) Did you or an affiliated person receive a compensation payment in
excess of $10,000 from-an organization? 

if "Yes," explain and, specify which one if you checked multiple-
organizations above:

Page 3 of 5

 



LESW



XE

 



 



 

.r

CONFLICT OF INTEREST QUESTIONNAIRE
FISCAL YEAR 7/1/2016 - 6/30/2017

Printed Name:

 

7) Did you or an affiliated person receive grants or other assistance,
including provision of goods, services, or use of facilities from an
organization? .Grants include scholarships, fellowships, internships,
prizes, and awards.

if ?Yes," explain and, specify which one if you checked multiple

organizations above: -

8) Do you have 35% control in an entity that received grants or other
assistance, including provision of goods, services, or use of facilities
from an organization? 

If "Yes," explain and, specify which onejf you checked multiple.
organizations above:

9) Do you have any loans to or from an organization?

If "Yes," explain and, specify which one if you checked m?ultiple
organizations above: -

10) Are you aware of?any excess benefit transactions to'report? An excess
benefit transaction is where an organization is directly or indirectly

provided an economic benefit where the value of the benefit exceeds the

value of the consideration received by the organization.

If "Yes," explain and, specify which one if you checked multiple
organizations above: . .

Page 4 of 5

 

LES

ES.

.1155

ES

 

M,

 

ULF-OO7287

 

 OF INTEREST 
FISCAL YEAR 7/1/2016 - 

Printed Name:

 

15$ .MZ.. ..

11) Are you or any affiliated persons a party to, or have an interest in, any i" {re/I
pending legal proceeding involving an organization?

If Yes,? explain, and if an affiliated person is involved the identity of that
affiliated person and your relationship with that person:

as



12) Are you aware of any other events, transactions, arrangements or other
situations that have occurred or may occur in the future that you believe
should be examined byan organization's governing body?

if "Yes explain and specify which one if you checked multiple
organizations above:

as we
WQ say 

Date: 

 

 

 

Page 5 of5
ULF-OO7288