Pursuant to the purposes and intent of the policy adopted by the Agency, requiring the disclosure of certain interests and conflicts. I hereby state that I have received a copy of the policy and understand that my responsibilities to the agency require that I disclose any duality of interest or possible conflict of interest, for myself and any member of my immediate family. that I will not vote or use influence on any matter in which I have a conflict or duality of interest: and will not accept gifts. favors. or hospitality with a monetary value in excess of $25.00, and will make every effort to Comply with the Agency Policy.

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I hereby disclose the following interests and activities of possible conflicts:

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