C6NFLICT OF INTEREST QUESTIONNAIRE
FISCAL YEAR 7/1/2016 - 6/30/2017

. PrintedName: 76? 

 

Check all covered companies Average
and note average hours spent hours per
MB per week. week:

l'f'
UofL Foundation (U LF)

. - It? 
UofL Housing (ULH)

University Holdings; Inc.
.

1..

The Nucleus Real.
Properties, Inc. (TNRP)

. l?
UofL Real Estate
Foundation, Inc; (ULREF)

I 1?7
Pediatric Medical Office
. Building, inc. (PMOB)


Louisville Medical

Center Development
Corporation 

Other Entity(s): 

 

Page 1 of5

ULF-OO7319

 

 OF INTEREST QUESTIONNAIRE
FISCAL YEAR 7! 1/ 201.6 - 

Printed Name:

 

When used below, the term I?affiliated persons" include the following:?
your spouse, domestic partner, child, mother, father, brother or
sister; (ii) 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
which yOu 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 3 Covered Company's tax year or-ongoing from
a prior yea r. Business transactions also include joint yentu res: 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} above:



2) Do you or an affiliated person own 35% of an entity (ii?corporation, ii? 
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
arid, specify which one if you checked multiple 

 

 

 

Page 2 of 5

ULF-OO7320

 

CONFLICT OF INTEREST QUESTIONNAIRE
FISCAL- YEAR 7/1/2016 

Printed Name:

 

3) Do you or an affiliated person, in combination with other affiliated

person(s)" own 35% of an entity (C-corporation, S?corporation,

- Partnership, 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:

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 transactionls) with the organization
and, specify which one if you checked multiple organization(s) above:

5) Do you or an affiliated person serue'as a partner, member, or
shareholder of an entity (with ownership interest in Excess of 5% of a
partnership or professional corporation) that conducts busineSs with an
organization? .

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

 

EELS





35.5.

 

 







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 onle 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 multiple
organizations above: - .

10) Are you aware ofany 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

 

to

re

1E5

IE5,

 

 

ULF-OO7322

CONFLICT OF INTEREST QUESTI-omnmee
FISCAL vane 7/1/2016 - 5/30/2017

?3

Printed Name:

 

3&5: 

11) Are you or any affiliated persons a party to, or have an interest in, any . 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:



12) Are you aware of any other events, transactions, arrangements or other i? F'l/
situations that have occurred or may occur in the future that you believe
should be examined byian organization 5 governing body? a 

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

Signature: r?
Date: 4/
/Z%e

 

 

 


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