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

Printed Name: 
f-gr.. -- 

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

I i .

l7.?
Uofl. Foundation (ULF)

r" .
UofL Housing (ULH)

 

University Holdings, Inc.


l?
The Nucleus Real
Properties, Inc. (TNRP)

rm- 0-
Uo?. Real Estate
Foundation, Inc. (ULREF)

 

r. l. .

Pediatric Medical Office
. Building, Inc. (PMOB)

r? l. i 

Louisville Medical
Center Development
Corporation 

Other Entity(s):

Page 1 of 5

 

ULF-OO7294

 

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

 

~(ld0 affair/-

When used below, the term "affiliated persons? include the following:
(5) 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.

Printed Name:

it:
I.

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. 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
XEE 

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 (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 organization(s) above:

 

 

 

Page 2 0f 5 LF-OO7295

 

CONFLICT OF INTEREST QUESTIONNAIRE
FISCAL YEAR 7/ 1] 2016 - 6/ 30/ 20 

   
 

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?

- if "Yes," describe your business the organization
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?

I if ?Yes," describe your business transactionis) 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 0f 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:

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X1215.



XE

1E5.

 

 

ULF-OO7296

 

 or INTEREST QUESTIONNAIRE
FISCAL YEAR 7/1/2016 - 5/30/201

it? s. {21:49 

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 facilities
from an organization? .

If "Yes," 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 m'ultiple
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 ULF-OO7297

 

CONFLICT OF INTEREST QUESTIONNAIRE
FISCAL YEAR 6/30/2 7

 

 

Printed Nameany affiliated persons a party to, or have an interest in, any
- 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
situations that have occurred or may occur in the future that you believe
should be examined byvan organization's governing body?

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

Signature:
Date:

 

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LES

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ULF-QO7298