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About NYSSCPA

Group II Conflict of Interest Disclosure Statement

The form below is for the date range of June 1st, 2015 - May 31st, 2017.

If you need a form for a different year, please choose one of the dates below:

  • To fill out the form for the date range of June 1st, 2015 - May 31st, 2016, click here.
  • To fill out the form for the date range of June 1st, 2016 - May 31st, 2017, click here.
ALL ANSWERS ARE TO BE GIVEN TO THE BEST OF YOUR INFORMATION AND BELIEF.

THE NEW YORK STATE SOCIETY OF CERTIFIED PUBLIC ACCOUNTANTS (“NYSSCPA”), THE FOUNDATION FOR ACCOUNTING EDUCATION, INC. (“FAE”), THE NYSSCPA CPAPAC, INC. (“PAC) AND ANY AFFILIATED COMPANY ARE INDIVIDUALLY AND COLLECTIVELY REFERRED TO HERE AS THE “SOCIETY”. Note: Defined terms have the meaning given them in the Policy.

I am submitting this disclosure statement to comply with the NYSSCPA Conflict of Interest Policy (the “Policy”). I recognize that am completing this form disclosing Conflicts of Interest and potential Conflicts of Interest that I have AND ALSO Conflicts of Interest and potential Conflicts of Interest that arise by virtue of “Related Parties” and “Affiliated Organizations” as such terms are defined in the Policy.
*I am completing this disclosure statement to qualify for service as (check all applicable)










 
 
 
*1) I declare that I have read and will abide by the NYSSCPA Conflict of Interest Policy (Approved by the NYSSCPA on October 2, 2003 and by FAE on November 17, 2003).

 
*2) Have you or any Related Parties or Affiliated Organizations provided compensated services or property to Society in the past year?

 
 
*3) With the exception of NYSSCPA membership and FAE courses at which you or a Related Party have been a paid attendee, have you or any Related Parties or Affiliated Organizations purchased services or property from the Society in the past year?

 
 
 
 
*4) Please indicate whether you or any Related Parties or Affiliated Organizations had, have, or will have any direct or indirect interest in any business transaction(s) in the past year to which the Society was or is a party?

 
 
 
*5) With the exceptions of your NYSSCPA membership dues, FAE courses for which you or a Related Party have registered and travel advances, were you or any Related Parties or Affiliated Organizations indebted to pay money to the Society at any time in the past year?

 
 
 
*6) Other than travel reimbursements, in the past year, did you or any Related Parties or Affiliated Organizations receive, or become entitled to receive, directly or indirectly, any personal benefits from, or as a result of your relationship with, the Society that in the aggregate could be valued in excess of $1,000?

 
 
 
*7) Are you or any Related Parties or Affiliated Organizations a party to, or have an interest in, any pending legal proceedings involving the Society?

 
 
*8) Are you aware of any other events, transactions, arrangements or other situations that you believe should be examined by the NYSSCPA President or other Presiding Officer in accordance with the terms and intent of the Policy?

 
 
 
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By submitting this form, I HEREBY CONFIRM that I have read and understand the Policy and that, to the best of my information and belief, my responses to the above questions are complete and correct.