This is the annual disclosure form filed by everyone on our Board, every officer, every member of executive staff, and anyone else with decision-making authority at Stimpunks Foundation. It is the companion to our Conflict of Interest Policy — the policy says what we will do about conflicts, and this is the form that finds them.
This Page Is Public. Your Answers Are Not.
Anyone can read this page. Nobody can read what you submit through it. We are saying that plainly rather than leaving you to work it out, because a form sitting on a public URL invites exactly the wrong assumption.
Completed statements go to our governance records and are reviewed by the Board. They are never published. Where a conflict actually affects a decision, we may describe the decision in our accountability materials — never your household, your family, or your finances. How long we keep them, and what gets deleted, is set out in our Document Retention & Destruction Policy.
Why We Publish a Blank Compliance Form
Most organizations keep this behind a login, and most small nonprofits that need one end up buying a template or paying a consultant for a sample. We default to open, and that includes the operational plumbing — not just the parts that flatter us.
So take it. If you run a small nonprofit and need a conflict of interest statement, copy this one, change the names, and use it. The pieces we think matter most are the ones templates usually get wrong:
- Disclosing is not an accusation. Most people who fill this out will have something to write down. Having a conflict is normal. Hiding one is the problem.
- The circle is wide, and you do not have to name anyone. Describing a relationship — “my partner,” “someone in my household” — is enough. Chosen family counts.
- There is another way in. If filling out a form is a barrier, we take the answers however works — out loud, over email, in a call — and transcribe them for review and signature. Needing a different way in is not a reason to skip a compliance obligation.
- It asks about divided loyalty, not about capacity. Your health, your care responsibilities, and how much time you have are not conflicts of interest, and we do not ask about them.
Reuse is welcome under our usual license. If it helps, we would like to hear about it.
The Form
Most people finish it in about ten minutes. You will need to sign at the end, with a mouse, trackpad, or finger.
Document ID: SF-GOV-COI-STMT-1.0
Status: Draft — pending adoption by the Board of Directors
Companion to: Conflict of Interest Policy (SF-GOV-COI-2.0)
Adapted from: Board Conflict of Interest Statement sample, Nonprofit Insurance Alliance Group, rev. 12.0724
If you have signed this form, the version above is the one you agreed to.
Related:Conflict of Interest Policy · Whistleblower & Concern Reporting Policy · Board & Governance · Accountability & Transparency · Forms