MONTALVO ARTS CENTER

CONFLICT OF INTEREST DISCLOSURE STATEMENT

FISCAL YEAR 2009-2010

Please complete each question to the best of your knowledge and belief with regard to FY 2009-2010.
Please check the box that applies. A “yes” answer does not imply that the relationship or transaction is/was
necessarily inappropriate. For “yes” answers to questions 3 through 8, please note explanation(s) in the
section after question 8.

1. Have you read Montalvo’s Ethics Code for the Board of Trustees?
No Yes

2. Do you agree to comply with Montalvo’s Ethics Code for the Board of Trustees (*or if you are a Montalvo
staff member, do you agree to comply with the conflict of interest and other applicable policies set forth in
Montalvo’s Ethics Code)?
No Yes

3. Do you or any immediate family have any relationships or engage in any activities of which you are aware
that may place you in a position of having conflict of interest with Montalvo or may create the impression of
a conflict except as noted below?
No Yes If yes, please explain in section after question 8.

4. Does Montalvo have a business relationship with any entity of which you or any of your immediate family
members are a trustee, officer, director, or employee?
No Yes If yes, please explain in section after question 8

5. Does Montalvo have a business relationship with any entity from which you or any of your immediate
family members directly or indirectly have received any compensation, income, loans or gifts?
No Yes If yes, please explain in section after question 8.

6. Does Montalvo have a business relationship with any entity in which you or any member of your family
holds an ownership interest in a closely held company or at least a 5% ownership interest in a public
company?
No Yes If yes, please explain in section after question 8.

7. Are you aware of any affiliations, employment or other matters involving you or any of your family not
disclosed above that might be perceived to compromise your obligations to Montalvo and should therefore
be reported in light of the Ethics Code?
No Yes If yes, please explain in section after question 8.

8. Do you have a business or family relationship with a trustee or staff member of Montalvo?
No Yes If yes, please explain in section after question 8.

If you have answered “Yes” to any of questions 3 through 8, please explain here:

I have answered all questions to the best of my knowledge and belief. I agree to supplement this statement in
the event of any changes of information during FY 2009-2010.

Signature______________________________ Date_______________
1
Trustee
Staff