Part A: To be Completed by Directors, Director Nominees, Officers and Key Employees

  Please identify, to the best of your knowledge, any and all entities of which you are an officer, director, trustee, member owner (either as a sole proprietor or a partner), or employee and with which the SikoraArts, Inc. (the "Organization") has a relationship:

 

 

  Please identify, to the best of your knowledge, any and all transactions in which the Organization is a participant and in which you have or might have a financial or personal interest:

 

 

  Have you or any "relative" (as defined in the Conflict of Interest and Related

Party Transaction Policy), had or engaged in, or do you know of any other

"Covered Person" (as defined in the Conflict of Interest and Related Party Transaction Policy) that has or engaged in, any of the following? (other than matters already fully disclosed, evaluated and resolved):

  Yes No

1 . a direct or indirect interest (financial or otherwise) in a transaction, agreement or any other arrangement and in which the Organization or any affiliate participates?  

2. a compensation arrangement or other interest in a transaction with the Organization?  

3. a compensation arrangement or other interest in or affiliation with any entity or individual that: (a) sells goods or services to, or purchases goods or services from, the Organization; (b) competes with the Organization; or (c) the Organization has, or is negotiating, or contemplating negotiating, any other transaction or arrangement with?  

4. used your/their position, or confidential information or the assets of the Organization to your/their (or an affiliated party's) personal advantage or for an improper or illegal purpose?  

   

5. solicited or accepted any gift, entertainment, or other favor where such gift might create the appearance of influence on you/them (other than gifts of nominal value, which are clearly tokens of respect and friendship unrelated to any particular transaction ?  

6. acquired any property or other rights in which the Organization has, or you/they know or have reason to believe at the time of acquisition that the Organization is likely to have, an interest?  

 an opportunity related to the activities of the Organization that is available to the Organization or to you/them, unless the Board has made an informed decision that the Organization will not pursue that opportunity?  

8. indebtedness to the Organization, other than for amounts due for ordinary travel and expense advances?  

9. any other circumstances that may, in fact or in appearance, make it difficult for you/them to exercise independent, objective judgment or otherwise perform effectively?  

If yes, to any of the above please describe the relevant facts (attach a separate sheet if necessary):

 

 

 

 

 

Part B: To be Completed by Directors Only 

    

  Yes No

1 . Have you been an employee of the Organization or an "affiliate"

(as defined in the Conflict of Interest and Related Party

Transaction Policy) of the Organization within the last three ears?  

2. Do you have a "relative" (as defined in the Conflict of Interest and Related Patty Transaction Policy) who has been a "key employee" (as defined in the Conflict of Interest and Related Party Transaction Policy) of the Organization or an affiliate of the Organization within the last three years?  

3. Have you received and/or do you have a relative who has received more than $10,000 in direct compensation from the Organization or an affiliate of the Organization in any of the last three fiscal years (not including reasonable compensation or reimbursement for services as a director)?  

4. Do you have a financial interest in and/or are you an employee of, any entity that has made payments to or received payments from, the Organization or an affiliate of the Organization in excess of the lesser of: (a) $25,000 or (b) 2% of such entity's consolidated gross revenue over the last three years (which payments do not include charitable contributions)? If so, what is or was the nature of your financial interest or relationship?  

5. Do you have a relative who has a financial interest in and/or who is an officer of, any entity that has made payments to or received payments from, the Organization or an affiliate of the Organization in excess of the lesser of: (a) $25,000 or (b) 2% of such entity's consolidated gross revenue over the last three years (which payments do not include charitable contributions)? If so, what is or was the nature of your relative's financial interest or relationship ?  

If yes, to any of the above please describe the relevant facts (attach a separate sheet if necessary):

The answers to the foregoing questions are stated to the best of my knowledge and belief. I also acknowledge that I have received a copy of, read and understood the Conflict of Interest and Related Party Transaction Policy and Whistleblower Policy of the Organization and agree that I have adhered and will continue to adhere to such policies.

Additionally, I understand that in order to maintain its federal tax exemption the

Organization must engage primarily in activities that accomplish one or more of its tax

 

exempt purposes.  

Date:

 

 

Signature:

 

Printed Name: