CONFLICT OF INTEREST QUESTIONNAIRE FISCAL YEAR 1! 2016 .. 6480/2017 Printed Name: Check all covered companies Average and note average hours spent hours per week; [0 per week. l7 UofL Foundation (U LF) I . UofL Housing (ULH) University Holdings, Inc. (UHll The Nucleus Real. Properties, inc. (TNRP) l" UofL Real Estate Foundation, Inc. (ULREF) - Pediatric Medical Office Building, inc. (PMOB) l? Louisville Medical Center Development Corporation Other Entity(s): Page 1 of 5 ULF-OO7274 CONFLICT OF QUESTIONNAIRE FISCAL YEAR 7/1/2016 - Printed Name: When used below, the term ?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 "business transactions" include, but are not limited to, contracts of sale, lease, license and performance of services, whether initiated during-a Covered Company'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 organizationls) above: 2) Do you or an affiliated person 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 transactionis] with the organization and, specify which one if you checked multiple organization(s) above: Page 2 of 5 1% ULF-OO7275 CONFLICT OF INTEREST QUESTIONNAIRE FISCAL YEAR 7/ 1/ 2016 - 6180/2017 Printed Nameaffiliated person, in combination with other affiliated person(s)" own 35% of an entity (ti-corporation, S?corporation, Partnership, LLC or other entity type), directly or indirectly, that conducts business with an organization? - If "Yes," describe yourbusinEss theorganization and, specify which one if you checked. multiple organization(s) above: 4) 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 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 an organization? if "Yes," describe your business transaction(s) 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 Em ULF-OO7276 CONFLICT OF INTEREST QUESTIONNAIRE FISCAL YEAR 7/ 112016 6/ SDI 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 froman organization? If explain and, specify which one if 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 r1222 LES E5. ULF-OO7277 CONFLICT OF INTEREST QUESTIONNAIRE FISCAL YEAR 7/ 1/ 2016 6/30/2017 Printed Name: 11') Are you or any affiliated persons a party to, or have an interest in, any pending legal proceeding involving an organization? lf Yes," explain, and if an af?liated person is involved, the identity of that affiliated person and your relationship with that person: 115.5 N0 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 by?an organization's governing body? it "Yes," explain and, specify which one if you checked multiple organizations above: Signature: Date: I '57, Page 5 ofIS ULF-OO7278