The purpose of disclosure of financial and personal interests (business, professional, or political) of JCPC members is to avoid conflicts of interest, potential conflicts of interest and the appearance of conflicts of interest between the member’s private interest and his/her public duties. It is critical to this process that JCPC members examine, evaluate, and disclose those personal and financial interests that may pose a real or potential conflict of interest. Each JCPC member must take an active, thorough, and conscientious role in the disclosure and review process, including having a complete knowledge of how the JCPC member’s private interests (business, professional, or political) might impact his/her position or duties on the council. JCPC members have an affirmative duty to provide any and all information that a reasonable person would conclude is necessary to disclose any conflict of interest, potential conflict of interest, or the appearance of a conflict of interest between the member’s public and private interests; however the disclosure, review, and evaluation process is not intended to result in the disclosure of unnecessary or irrelevant personal information.

Therefore, personal relationships that may inappropriately influence (bias) or appear to influence actions must be disclosed. Conflict means a conflict or the appearance of a conflict between the private interests and official responsibilities of a person in a position of trust, including a Juvenile Crime Prevention Council member. [Examples of conflict of interest include, but are not limited, to a JCPC member being related to a JCPC funded program staff member, a JCPC member being employed by a competing applicant for JCPC funding, or a JCPC member or managing staff having personal, financial, professional, or political gain at the expense or benefit of the JCPC; other than the benefit of therapeutic intervention for the juveniles and families served by JCPC funded programs.]

Failure to disclose any conflicts of interest, potential conflicts of interest and the appearance of conflicts of interest within the JCPC may result in the DPS cessation of any further State funds.

1) Are you, your spouse, or any other members of your family serving as a program manager, employee, director, officer, or governing board member of any organization for which the JCPC has funding interest or jurisdiction? No Yes (If yes, please describe below.)

Name	Identify Name of Program or Organization	Position (Program manager, director, officer, employee or board member)

2) Are you aware of any other information necessary to fully disclose any actual, potential, or the appearance of conflicts of interest you may have during the course of fulfilling your duties and responsibilities as a JCPC member? No Yes (If yes, please describe below.)

3) If replying yes to either of the above questions, the JCPC Chairperson must attach a description of the steps that will be taken by the JCPC to address any conflict of interest, potential conflicts of interest and the appearance of conflicts of interest. The description must include the name and address of the persons involved and a description of the relationship and any potential transaction.

County or Counties
JCPC member's name (Print, Sign, Date)
JCPC Chairperson's name (Print, Sign, Date)

Date Received in County Manager’s Office: _______________ Date Received in DPS Area Office: _____________