Group I Conflict of Interest Disclosure Statement

The form below is for the date range of June 1st, 2026 - May 31st, 2027.

To qualify for service as (check all applicable)

Chairperson of an NYCPA, FAE, MSF, or PAC Committee (other than those included in Group II of the NYSSCPA/FAE/MSF/PAC Conflict of Interest Policy)

Member of a Chapter Executive Board

Other

If other, please specify

I declare that

1. I have read the NYCPA/FAE/MSF/PAC Conflict of Interest Policy (Approved by the NYSSCPA on February 12, 2020, by FAE on June 6, 2020, by MSF on April 30, 2020, and by PAC on July 19, 2020), and

2. To the best of my information and belief, I, my Related Parties, and Affiliated Organizations have no relationships at present with the Society which could give rise to a Conflict of Interest other than the following:

3. I agree to recuse myself from any Society-, FAE-, MSF-, and/or PAC-related decisions in which I believe I might have a Conflict of Interest.

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Note: Defined terms have the meaning given them in the Policy

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