(CONFIDENTIAL)

Disclosure of Significant Financial Interests

Related to Projects Funded by NSF or Other Sponsor

All Investigators must complete this form if they have responsibility for the design, conduct or reporting of the sponsored research or educational activities. Investigators include principal investigators and co-investigators as defined in the Policy and Procedures.

Name of Investigator: ______(Employee ID: ______)

Division: ______

Proposal Number(s):______

Type of Disclosure (circle one): NewRevised

In accordance with the attached instructions, disclose all Significant Financial Interests that would reasonably appear to be affected by the proposed research or educational activities:

  1. List separately those sources of salary, or other payments for services such as consulting fees or honoraria, income from intellectual property rights and gifts that, when aggregated for you, your spouse, and dependent children, are expected to exceed $10,000 (for gifts $1000), during the next twelve month period (if none, write none below).
  1. List separately those equity interests that, when aggregated for you, your spouse, and dependent children, both exceeds $10,000 in fair market value, and represents more than 5% ownership interest in any single entity (if none, write none below).

I certify that the information given above is complete and true to the best of my knowledge and that I have read and understood the attached instructions and the related policy entitled “Investigator Financial Disclosure Policy”.

Signature: ______Date: ______

Division Director Approval: ______Date: ______

INSTRUCTIONS FOR REPORTING SIGNIFICANT FINANCIAL INTERESTS RELATED TO PROJECTS SPONSORED BY NSF

Investigators are required to disclose to UCAR all Significant Financial Interests, as defined below that would reasonably appear to be affected by the funded research or educational activities. This regulation further requires that disclosures be filed prior to the submission of grant and contract proposals for review by NSF.

To comply with these regulations, you must complete the attached disclosure form and submit it to your Division/Program Director. If your Director or UCAR Management determines that a conflict exists, a plan to manage, reduce or eliminate the conflict must be developed and approved by your Director prior to the expenditure of any funds.

Definition of Significant Financial Interest. The term “Significant Financial Interest” means anything of monetary value, including but not limited to salary or other payments for services (e.g., consulting fees or honoraria); equity interest (e.g., stocks, stock options or other ownership interests); intellectual property rights (e.g., patents, copyrights, and royalties from such rights) and gifts over $1000.

The term does not include:

  1. salary, royalties or other remuneration from UCAR or other non- sponsors
  2. income from seminars, lectures, or teaching engagements sponsored by public or non-profit entities;
  3. income from service on advisory committees or review panels for public or non-profit entities;
  4. an equity interest that, when aggregated for the Investigator and Investigator’s spouse and dependent children, meets both of the following tests: does not exceed $10,000 in value as determined through reference to public prices or other reasonable measures of fair market value, and does not represent more than a five percent (5%) ownership in any single entity; or
  5. salary, royalties or other payments that, when aggregated for the Investigator and the Investigator’s souse and dependent children, are not expected to exceed $10,000 during a twelve month period excluding salary, royalties or other remuneration specified in a above.

OGC 8-03