Policy Receipt and Disclosure Statement - Mountains To Sound Greenway Trust

Disclosure Statement

Please review the statements for Items A and B below, then select the statement that is true for you. If selecting Item B, please describe.

A. I am not aware of any relationship or interest or situation involving my family or myself that might result in, or give the appearance of being, a conflict of interest between such family member or me on one hand and the Greenway Trust on the other.

B. The following are relationships, interests, or situations involving me or a member of my family that I consider might result in or appear to be an actual, apparent, or potential conflict of interest between such family members or myself on one hand and the Greenway Trust on the other.

Please select item A or B

Corporate (either nonprofit or for-profit) directorships, positions, and employment:

Memberships in the following organizations:

Contracts, business activities, and investments with or in the following organizations:

Other relationships and activities:

ACKNOWLEDGMENT AND SIGNATURE

To the best of my knowledge and belief, the above information is true and accurate. I have received a copy of the Greenway’s Conflict of Interest Policy, which I have read and understand, and I hereby agree to comply with it.

First Name

Last Name

Date