LACF Policies Annual Attestation Form

Please read the Confidentiality, Whistleblower, and Conflict of Interest policies that were recently emailed to you, then complete and submit this form. Due to your affiliation with La Crosse Area Community Foundation, you must review and attest to these policies on an annual basis for LACF to maintain its accreditation with National Standards for U.S. Community Foundations.

Confidentiality Policy
- By checking the box, I confirm that I have received a copy of the La Crosse Area Community Foundation Confidentiality Policy and agree to abide by the guidelines set forth therein.
Whistleblower Policy
- By checking this box, I confirm that I have received, understand, and will comply with the La Crosse Area Community Foundation Whistleblower Policy.
Conflict of Interest Policy and Disclosure Statement
In accordance with the Conflict of Interest Policy adopted by the Foundation’s Board of Directors, all board members and staff are asked to complete the following questionnaire. The policy provides that a board member with a Conflict of Interest may not vote on any matter with respect to which he or she has a Conflict of Interest, and that such business conflict, as described in item 1 of the questionnaire, also precludes voting on such matters. The Board Chair may request that a member not participate in a discussion of a possible grant in the case of a conflict with respect to that prospective grantee. To avoid being overly intrusive, you are not required to provide information about the interests of family members in the questionnaire, although if such a conflict exists with respect to a specific transaction or grant that is under consideration, you will be expected to disclose it.
Business Affiliations - List all relationships with any person, firm, company or other organization which, to the best of your knowledge, provided any goods or services with an annual value of $1,000 or more to the Foundation or its affiliates in any of the past five years. This would include any relationship as a director, officer, partner, owner or family member of the person or entity, as counsel, or if you received any gifts or loans from, or if you have a compensation or other financial arrangement with, the person or entity.
Nonprofit Organizations - List any relationships with nonprofit organizations. This would include any relationship as a director, officer or employee of the organization, as counsel to it, or if you have a compensation or other financial arrangement with the organization.
Other - List any other activities during the past year that might be interpreted as a possible conflict of interest with your role with La Crosse Area Community Foundation.
- By checking this box, I confirm receipt and understanding of the La Crosse Area Community Foundation Conflict of Interest Policy. I also certify that to the best of my knowledge the information I've disclosed is complete and accurate, and that I agree to report promptly to the Chair of the Board of Directors any changes in my disclosure responses.
Please check all appropriate boxes below indicating your involvement with La Crosse Area Community Foundation:*
- LACF Board Member
- LACF Committee Member
- LACF Staff
- Other (Vendor, Consultant, etc.)
Date*
Signature*

LACF Policies Annual Attestation Form

Confidentiality Policy

Whistleblower Policy

Conflict of Interest Policy and Disclosure Statement