DePauw University Conflict of Interest Questionnaire

Transcription

1 Conflict of Interest Questionnaire 1) Other than an employment relationship, do you or a family member conduct business with this organization? Business transactions include, but are not limited to contracts of sale, lease, license and performance of services, whether initiated during the organization'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%. 2) Do you or a family member own 35% of an entity (C-corporation, S-corporation, ship, LLC or other entity type), directly or indirectly, that conducts business with the organization? 3) Do you or a family member, in combination with other "interested person(s)" own 35% of an entity (C-corporation, S-corporation, ship, LLC or other entity type), directly or indirectly, that conducts business with the organization? A link to the list of other "interested persons" for this organization is located at the beginning of this survey (left-hand side). 4) Do you or a family member, serve as an officer, director, trustee, or key employee of an entity that does business with the organization? 5) Do you or a family member serve as a partner, member, or shareholder of an entity (with ownership interest in excess of 5% of a partnership or professional corporation) that conducts business with the organization?

2 6) Did a family member receive a compensation payment in excess of $10,000 from the organization? 7) Did you or a family member receive grants or other assistance, including provision of goods, services, or use of facilities from this organization? Grants include scholarships, fellowships, internships, prizes, and awards. 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 this organization? 9) Do you have any loans to or from this organization? 10) Are you aware of any excess benefit transactions to report? An excess benefit transaction is where the organization directly or indirectly provided an economic benefit where the value of the benefit exceeds the value of the consideration received by the organization. 11) Do you have a family or business relationship with any other officer, director, trustee, or key employee of the organization? A list of 's interested persons is included on the following pages. Name Signature: Date

3 Board of Trustees and their affiliations Lisa Henderson Bennett 93 Ashburn, VA Thomas W. Boswell 66 /CEO, Retired Overnite Transportation Kiawah Island, SC Kenneth W. Coquillette 82 Investment Banking Division Goldman Sachs & Co. Sally G. Cowal 66 Senior Vice /Chief Liaison Officer Population Services International Washington, DC Michael J. Coyner, Friend Bishop, Indiana Area United Methodist Church Jeffrey A. Cozad 86 Co-Founder and Managing Stonerise Capital s San Francisco, CA Newton F. Crenshaw 85 Vice Oncology Business Unit, U.S. and Canada Eli Lilly and Company Mrs. Marletta Darnall 61 Matthew S. Darnall 85 Goldman, Sachs & Company David R. Dietz 11 Obama for America Jane L. Emison Friend Owner, Retired Jane Larson Emison Designs Wayzata, MN Marvin E. Flewellen 85 Senior Director Invesco Worldwide Fixed Income Louisville, KY James R. Gates 78 TPG Capital San Francisco, CA Adam M. Gilbert 10 Omnicom Media Group Max W. Hittle, Jr. 66 Krieg Devault, LLP R. David Hoover 67 Chairman of the Board Ball Corporation Boulder, CO Matthew R. Jennings 09 Teach for America Janet L. Johns 85 SVP Business Development C4 Services, LLC Marietta, GA Kyle E. Lanham 79 GoodSource Global, LLC G. Richard Locke, III, M.D. 83 Gastroenterologist and Professor of Medicine Mayo Clinic Rochester, MN

4 Board of Trustees and their affiliations Erik G. Nelson 61 Chief Financial Officer, Retired Procter & Gamble Co. Cincinnati, OH Richard S. Neville 76 Western Petroleum Company Eden Prairie, MN Myrta Pulliam, Friend Director of Special Projects The Indianapolis Star Marshall W. Reavis IV 84 SVM, LP Des Plaines, IL Blair A. Rieth, Jr. 80 Vice, Investor Relations and Investor Relations Officer Hill-Rom Batesville, IN Darlene M. Ryan 76 Executive Director TECH Fort Worth Fort Worth, TX Douglas I. Smith 85 Miller & Smith McLean, VA James G. Stewart 64 Executive Vice and CFO (Retired) Cigna Corporation Bryn Mawr, PA Lee E. Tenzer 64 Owner/Manager, Retired LETCO Naples, FL Steven L. Trulaske 79 Owner True Manufacturing Company O'Fallon, MO Marcus R. Veatch 75 Executive Director, Retired Verizon Communications, Inc. Kathy P. Vrabeck 85 Heidrick & Struggles Los Angeles, CA Sarah R. Wallace 76, Chairman of the Board First Federal Savings and Loan Association of Newark Newark, OH Bayard H. Walters 63 Cromwell Group, Inc. d/b/a Cromwell Radio Group Nashville, TN M. Scott Welch 82 Chief Executive Officer Welch Packaging Group Elkhart, IN Robert F. Wells 66 Executive Vice, Retired Young & Rubicam, Inc. South Londonderry, VT R. Lee Wilson 76 and CEO First Capital Boca Raton, FL Corinne Gieseke Wood, Parent Former Lieutenant Governor, State of Illinois Lake Forest, IL

5 Officers Brian Casey Cindy Babington Vice for Student Life/Dean of Students David Harvey Vice for Academic Affairs Bradley A. Kelsheimer Vice for Finance and Administration Marcia Latta Vice for Advancement Dan Meyer Vice for Admission and Financial Aid Christopher Wells Vice for Communications and Strategic Initiatives