Owner's Certification Re: Conflicts of Interest

APPENDIX A-5

OWNER'S CERTIFICATION RE: CONFLICTS OF INTEREST

The undersigned Owner acknowledges and discloses the following conflicts of interest between the Owner or any of its partners, managers or members or affiliates and any of the companies providing professional services in connection with the Qualified Contract Request (each, a "Professional Service Provider") submitted for ______(insert name of project) as listed below. If no conflict of interest exists, indicate "None". If a conflict does exist, please indicate the nature of the relationship and the percentage of ownership, if applicable.

Appraiser:

CNA Provider:

Environmental Consultant:

Other:

A conflict of interest is considered to exist if:

§  the Owner holds, directly or indirectly, any financial interest in any Professional Service Provider;

§  one or more officers, directors, stockholders, managers, members or partners of the Owner is also an officer, director, stockholder, manager, member or partner of any Professional Service Provider;

§  any Professional Service Provider advances funds to the Owner; or

§  any Professional Service Provider takes any stock or interest, including an indirect or beneficial interest, in the Owner as consideration to be paid to it for a professional service rendered in connection with the project named above or any other project in which the Owner has an interest.

For purposes of this Certification, "Owner" shall include any manager, officer or director of the Owner, and any stockholder, manager, member, partner or person who holds (directly or indirectly) a financial interest in the Owner, and any member of the family of any manager, officer or director of, or any stockholder, manager, member, partner or person holding (directly or indirectly) a financial interest in, the Owner. For purposes of this Certification, "Professional Service Provider" shall include the Appraiser, the CNA Provider, the Environmental Consultant and any other professional service provider, and any manager, officer or director of, and any stockholder, manager, member, partner or person holding (directly or indirectly) a financial interest in, the Appraiser, the CNA Provider, the Environmental Consultant or any other professional service provider, and any member of the family of any manager, officer or director of, or any stockholder, manager, member, partner or person holding (directly or indirectly) a financial interest in, the Appraiser, the CNA Provider, the Environmental Consultant or any other professional service provider.

( NAME OF OWNER )

By:

( insert name of signatory )

Its: ( insert title )