CONFLICT OF INTEREST QUESTIONNAIRE
FISCAL YEAR 7/1/2015 - 6f30f2017

Printed

Name: 

   

c/ Average

Check-ail covered companies and note average hours spent hours per
Organization w- .
oft. i=3. 
Foundation
(ULF)

  

 

Uofi. Housing
(ULH)

 

University 13
Holdings, Inc.


The Nucleus Fl
Real
Properties,
Inc. (TNRP)

UofL Real 
Estate
Foundation,
Inc. (ULREF)

Pediatric I:
Medical
Office
Building, Inc.
(PMOB)

 

 

 

 

Louisville
Medical
Center
Development
Corporation


Other
Entityls):

 

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ULF-OO7337

 

CONFLICT OF INTEREST 
FISCAL YEAR 711/2016 - 6/ 30! 2017

Printed
Name= 

When used below, the term persons" include the following: your Spouse,
domestic partner, child, mother, father, brother or sister; (ii) any corporation or
organization of which you area board member, an officer, a partner, participate in
management or are employed by, or are directly or indirectly, a debt holder or the
bene?cial owner of any class of equity securities; and any trust or other estate in
which you have a substantial bene?cial interest or as to which you serve as a trustee or
in a similar capacity.

 

55/% 1/1? a?

..

 

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 3
Covered Company's tax year or ongoing from a prior year. Bosiness transactions also
include joint ventures in which either the pro?ts or capital interest of the organization
and of the interested person exceeds 10%.

Business Transactions with Organization


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

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

2) Do you or an af?liated 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 transactionls) with the organization and, specify which
one if you checked multiple organization(s) above:

 

 

 

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ULF-OO7338

 

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

Printed

Name: . ..

 

?23:667/2/5

3] Do you or an af?liated person, in combination with other af?liated 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 transactionls) with the organization and, specify which
one if you checked multiple organizationls) above:

4) Do you or an af?liated person, serve as an of?cer, 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 organizationls) aboveas? ?rmer e74 ?27 . 
Mar @959, ?gs/mes 

?74 

5) Do you or an af?liated 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 multipie organizations above:

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1-55

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ULF-OO7339

 

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

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.

Printed
Name:

 

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 from an organization?

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

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

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

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

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

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LES

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ULF-OO734O

 

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

Printed

Name: 

   

 


11) Are you or any af?liated persons a party to, or have an interest in, any pending legal r' 
proceeding involving an organization?

if Yes," explain, and if an af?iiated person is involved, the identity of that af?liated person
and your relationship with that person:

ACE-S N2 
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?

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

 

 

 

  

.o/v

   

 

 

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ULF-OO7341