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EMPLOYMENT AND <br />ECONOMIC DEVELOPMENT Conflict of Interest Disclosure <br />State of Minnesota <br />Request for Proposals <br />Instructions: Please return your completed form as part of the Response submittal. <br />Conflict of interest Disclosure Form <br />This form gives applicants and grantees an opportunity to disclose any actual or potential conflicts of <br />Interest that may exist when receiving a grant. It is the applicant/grantee's obligation to be familiar with <br />the Office of Grants Management (OGM) Grants Policy 08-01 Conflict of Interest Policy for State Grant- <br />1 2 and to disclose any conflicts of interest accordingly. <br />All grant applicants must complete and sign a conflict of interest disclosure form. <br />IQ oor my grant organization do NOT have an ACTUAL or POTENTIAL conflict of interest. <br />If at any time after submission of this form, I or my grant organization discover any conflict of interest(s), <br />I or my grant organization will disclose that conflict immediately to the appropriate agency or grant <br />program personnel. <br />❑ I or my grant organization have an ACTUAL or POTENTIAL conflict of interest. (Please <br />describe below): <br />If at any time after submission of this form, I or my grant organization discover any additional conflict of <br />interest(s), I or my grant organization will disclose that conflict immediately to the appropriate agency or <br />grant program personnel. <br />Printed name: Scott PeJerson. GityCouncilor <br />Signature: 4L$_2E4� <br />Organization: City of Peauot Lakes <br />Date: 10 '?7 — Z Z <br />