UNIVERSITY OF LOUISVILLE BOARD OF TRUSTEES CONFLICT OF INTEREST STATEMENT YEAR 7/1/2015 - 6/30/2016 (Please return to Jake Beamer no later than October 8, 2015. You may scan and email (Jake.Beamer@louisville.edu) or return via post: Jake Beamer, Of?ce of the President, University of Louisville, Louisville, KY 40292 Organization UNIVERSITY OF LOUISVILLE Name of Individual Signature Md 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 profits or capital interest of the UofL and ofthe interested person exceeds 10%. If "Yes," describe your business transaction(s) with the UofL: 2. Do you or a family member own 35% of an entity (C?corporation, Sucorporation, Partnership, LLC or other entity type(s), directly or indirectly, that conducts business with the UofL? - If "Yes,? describe your business transaction(s) with the UofL: 1 AM mug-aw Wme? be; ijob?ifmimm Wm Ila-.3 I if- . egg/167:9" aura. WED WNW lm?7?o?5 fig) ??z-IMe 'J?po?z? mng? we 45% MW) bitm?m Db- Page 1 of 4 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 indirectly, that conducts business with the UofL? 0 If "Yes,? describe your business transaction(s) with the UofL: 4. Do you or a family member, serve as an officer, director, trustee, or key employee or an entity that does business with the UofL? If ?Yes," describe your business transaction(s) with the UofL: WWMJUW 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 business with the UofL? If ?Yes,? describe your business transaction(s) with the UofL: gagng??zzm?aMg?ga- Page 2 of4 6. Did a family member receive a compensation payment in excess of $10,000 from the UofL? - 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, including 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. 10. Are you aware of any excess benefit transactions to report? An excess benefit transaction is where the UofL directly or indirectly provided an economic benefit where the value of the benefit exceeds the value of the consideration received by the UofL. Page 3 of 4 up: D351 Dix Eli If "Yes," explain. Business and Family Relationships with Interested Persons 11. Do you have a family or business relationship with any other officer, director, trustee, or key 3% employee of the UofL? For each family and business relationship, identify the persons and indicate family or business relationship. Page 4 of 4