STATEMENT OF SIGNIFICANT FINANCIAL INTERESTS

(For Federal Grant Applications)

NAME (print)

DEPARTMENT/UNIT

COLLEGE

PROPOSAL TITLE

AGENCY National Science Foundation

Please provide a list of all external entities in which you (and your spouse or dependent children) have a Significant Financial Interest that could affect or be affected by the activity proposed for funding.

Please duplicate this sheet as needed and provide the following information for each external entity identified above.

1. NAME OF BUSINESS/ORGANIZATION NATURE OF BUSINESS

2. Person who has Significant Financial Interest

Self Spouse Dependent Child

3. Nature of Significant Financial Interest (Circle all that apply)

a) Equity interest

b) Consulting or employment

c) Director, officer, partner, agent, managerial or advisory position

d) Receipt of loan or gift

e) Receipt of honoraria for papers, lectures

f) Receipt of royalty revenue

g) Other (please specify below)

4. Relationship of external entity or activity to instructional, research, or service activities proposed for funding by federal agencies (Circle all that apply)

a) External entity sponsors instructional, research, or service activities for which I am Principal Investigator.

b) External entity sponsors instructional, research, or service activities in which I participate.

c) External entity does not sponsor my instructional, research, or service activities, but my instructional, research, or service activities could have financial implications for the external entity.

d) Other (please specify below)

5. Please provide any additional information, which will assist the University in reviewing and managing this Disclosure Statement. An additional sheet may be attached.

In submitting this form, I affirm that the above information is true to the best of my knowledge and that I have read the University’s Guidelines and Procedures on Conflicts of Interests Policies.

___________________________________ ________________________

Principal Investigator Date

To be retained in a confidential file in the Office of the Vice President for Research

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KSU OGC Form B (08/08)