Conflict of Interest - Annual Disclosure Statement

Office of Human Resources - Form 990 Disclosure Questionnaire

Respond to all questions for the period July 1, 2022 to the date you complete and sign this questionnaire.

Instructions:

This combined questionnaire is being sent to you to assist Xavier University in complying with the reporting requirements required in the filing of Form 990 - Return of Organization Exempt from Income Tax and in complying with Xavier University's Conflict of Interest Policy (COI). Form 990 and the COI require the disclosure of information relating to transactions between certain persons and Xavier University and any of its related organizations. Your completion of this form is important to allow Xavier University to accurately and completely accomplish its annual tax filing, governance and compliance requirements. Please answer the questions and provide descriptions as needed. Exhibit A is to assist you in completing question number 6 regarding family and business relationships. The Xavier University Conflict of Interest Policy ("COI Policy") provides definitions of key terms.

Please complete the questionnaire and submit by 9/30/2023.

Notes:

• This form includes the 12 months ending June 30, 2023 as well as matters that have arise since then and up to the date you complete and sign this questionnaire.
• "Xavier" or "University" refers to Xavier University and its following related organizations, most of which solely hold title to real property: XUPROP CO; XUPROPCO-Plaza; XUPROPCO-Cincinnati; XuPROPCO-Norwood; XUPROPCO-Dana; and Xavier University Student Health and Wellness Center Corporation.
• "Family members" is defined in the COI Policy.