Financial Disclosure Texas by hqs15688

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The University of Texas at Austin
FINANCIAL DISCLOSURE AND CONFLICT OF INTEREST STATEMENT
For Academic Year 2008-2009 and Fall Semester 2009

WHO COMPLETES THIS FORM? Please complete this Statement if you are an
employee with authority to execute contracts or you can exercise significant discretion
with regard to the award of contracts or other pecuniary transactions. UT System and UT
Austin have adopted a policy for financial disclosure by such employees. Please respond
to all questions for the period Academic Year 2008-2009 and continuing through the date
you are completing this form. Please also review the UT Austin Individual Conflicts of
Interest Policy and Section 572.051, Government Code.


I. NAME OF EMPLOYEE: _____________________________________________________
Position Held: __________________________________________________________________

II. NAME OF SPOUSE: ________________________________________________________
Name and Address of Spouse’s Employer: ____________________________________________
Position Held: __________________________________________________________________
If Spouse is Self-Employed, Nature of Occupation: _____________________________________

III. NAME OF DEPENDENT CHILD 1: ___________________________________________
Name and Address of Child’s Employer: _____________________________________________
Position Held: __________________________________________________________________
If Child is Self-Employed, Nature of Occupation: ______________________________________

NAME OF DEPENDENT CHILD 2: ______________________________________________
Name and Address of Child’s Employer: _____________________________________________
Position Held: __________________________________________________________________
If Child is Self-Employed, Nature of Occupation: ______________________________________

NAME OF DEPENDENT CHILD 3: ______________________________________________
Name and Address of Child’s Employer: _____________________________________________
Position Held: __________________________________________________________________
If Child is Self-Employed, Nature of Occupation: ______________________________________

                                    (Attach more pages as necessary.)


IV. List each business entity in which you, your spouse, or a dependent child has a substantial
interest, as defined below. Also indicate the position held, whether any compensation has been
received from the business entity, and the category of the type of interest as provided by Subsection
(c) below.

For purposes of this item:

(a) “Business entity” means any entity recognized by law through which business for profit is conducted,
including a sole proprietorship, partnership, firm, corporation, holding company, joint stock company,
receivership, or trust.
(b) “Compensation” does not include sources of “passive income,” such as alimony, child support,
interest on savings and investments, inheritances, annuities, pensions, or dividends.
(c) “Substantial interest” in a business entity means that during all or a portion of the reporting period:
      (1) a controlling interest;
      (2) ownership of more than 10 percent of the voting interest;
The University of Texas at Austin                                                                            2
FINANCIAL DISCLOSURE AND CONFLICT OF INTEREST STATEMENT
For Academic Year 2008-2009 and Fall Semester 2009
     (3) ownership of more than $25,000 of the fair market value;
     (4) a direct or indirect participating interest by shares, stock, or otherwise, regardless of whether
         voting rights are included, in more than 10 percent of the profits, proceeds, or capital gains;
     (5) service as a member of the board of directors, board of trustees, board of governors, or advisory
         board.
     (6) service as an officer; or
     (7) service as an employee.

Individual: ____________________________________________________________________
Name of Business Entity: _________________________________________________________
Office or Position Held: __________________________________________________________
Compensation: Yes _______         or No _______
Category of Interest (1 through 7 above): ___________

Individual: ____________________________________________________________________
Name of Business Entity: _________________________________________________________
Office or Position Held: __________________________________________________________
Compensation: Yes _______         or No _______
Category of Interest (1 through 7 above): ___________

Individual: ____________________________________________________________________
Name of Business Entity: _________________________________________________________
Office or Position Held: __________________________________________________________
Compensation: Yes _______         or No _______
Category of Interest (1 through 7 above): ___________

                                    (Attach more pages as necessary.)




V. List each nonprofit entity in which you, your spouse, or dependent child served as an officer or
member of the governing board, board of trustees, board of governors, or advisory board.

Individual: ____________________________________________________________________
Name of Nonprofit: _____________________________________________________________
Office or Position Held: __________________________________________________________

Individual: ____________________________________________________________________
Name of Nonprofit: _____________________________________________________________
Office or Position Held: __________________________________________________________

Individual: ____________________________________________________________________
Name of Nonprofit: _____________________________________________________________
Office or Position Held: __________________________________________________________

Individual: ____________________________________________________________________
Name of Nonprofit: _____________________________________________________________
Office or Position Held: __________________________________________________________

                                    (Attach more pages as necessary.)
The University of Texas at Austin                                                                            3
FINANCIAL DISCLOSURE AND CONFLICT OF INTEREST STATEMENT
For Academic Year 2008-2009 and Fall Semester 2009
VI. Identify any person or entity that has given a gift that exceeds $250 in value to you, your
spouse, or your dependent children. Do not include gifts received from:
         (1) your parent, child, sibling, grandparent, or grandchild;
         (2) the spouse of an individual listed in Paragraph (1); or
         (3) the parent, child, sibling, grandparent, or grandchild of your spouse.


Individual: ____________________________________________________________________
Donor of Gift: __________________________________________________________________
Brief Description of Gift: _________________________________________________________

Individual: ____________________________________________________________________
Donor of Gift: __________________________________________________________________
Brief Description of Gift: _________________________________________________________

Individual: ____________________________________________________________________
Donor of Gift: __________________________________________________________________
Brief Description of Gift: _________________________________________________________

Individual: ____________________________________________________________________
Donor of Gift: __________________________________________________________________
Brief Description of Gift: _________________________________________________________


                                     (Attach more pages as necessary.)


VII. To the best of your knowledge, do any of the business entities, nonprofit entities, or donors
identified in Items IV – VI above have any business relationship with UT System or UT Austin?
A business relationship includes transactions like a contract or grant between the entity and the
University; proposals made for business (or clearly anticipated); selling of goods and services to
(or from) the University; a lease of real property; a license of patents or trademarks; etc.
____ Yes              ____ No

If yes, provide the name of the entity and a brief description of the relationship with the U.T. System or the
institution.

Entity or Donor: ________________________________________________________________
Description of Relationship: _______________________________________________________

Entity or Donor: ________________________________________________________________
Description of Relationship: _______________________________________________________

Entity or Donor: ________________________________________________________________
Description of Relationship: _______________________________________________________

Entity or Donor: ________________________________________________________________
Description of Relationship: _______________________________________________________

                                     (Attach more pages as necessary.)
The University of Texas at Austin                                                                         4
FINANCIAL DISCLOSURE AND CONFLICT OF INTEREST STATEMENT
For Academic Year 2008-2009 and Fall Semester 2009

VIII. Do you have the capacity to affect University processes for the conduct, review, or
oversight of human subjects’ research?
Yes __________                       No _________
If yes, this statement will be reviewed additionally and jointly with the Vice President for Research
under procedures in the UT Austin Handbook of Operating Procedures, Policy Number 11.B.2,
Institutional Conflict of Interest in Human Subjects Research.

IX. ACKNOWLEDGMENT. By executing this document, I acknowledge that I
have read the Standards of Conduct provided by Section 572.051, Government Code
and the UT Austin Individual Conflicts of Interest Policy. The information I have
provided is for the purpose of assuring compliance with the Standards of Conduct and
the Regents’ Rules and Regulations, UT Austin policy, and disclosing possible
conflicts of interest. I understand that it is my responsibility to comply with the
Standards of Conduct, the Regents’ Rules and Regulations, UT Austin policy, and
any other applicable state law, rule, or policy governing conflicts of interest.

X. CERTIFICATION. I hereby certify that to the best of my knowledge and belief the information
provided by me in this financial disclosure statement is true and correct.


Signature: ________________________________________________

Date: ____________________________________________________


XI. REVIEW BY DEPARTMENT HEAD. I am the head of the department in which this employee
works. I have reviewed the information provided by the employee in this financial disclosure statement.


Signature: ________________________________________________

Print Name: _______________________________________________
Title and Department: _______________________________________
_________________________________________________________
Date: ____________________________________________________


XII. SUBMISSION BY DEPARTMENT HEAD. I have provided the completed form to the Office of
the Vice President for Legal Affairs, MAI 102, Mail Code:G4800, no later than January 31, 2010.

Questions may be directed to the Office of the Vice President for Legal Affairs at 471-1241 or
vpla@austin.utexas.edu.
The University of Texas at Austin                                                                       5
FINANCIAL DISCLOSURE AND CONFLICT OF INTEREST STATEMENT
For Academic Year 2008-2009 and Fall Semester 2009

                                NOTICE ABOUT INFORMATION LAWS

       With few exceptions, you are entitled on your request to be informed about the information UT
Austin collects about you. Under Sections 552.023 and 552.023 of the Texas Government Code, you are
entitled to receive and review the information. Under Section 559.004 of the Texas Government Code, you
are entitled to have UT Austin correct information about you that is held by us and that is incorrect. The
information that UT Austin collects will be retained and maintained as required by Texas records retention
laws (Section 441.180 et seq. of the Texas Government Code) and rules. Different types of information are
kept for different periods of time.

								
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