Division of Grants Administration

Conflict of Interest Disclosure

Complete and submit this form to disclose any potential conflict of interest concerning the expenditure of federal grant funds.
Limit one conflict of interest per form.
Completion and submission of this form satisfies the requirement in 2 CFR 200.112.
Name of Federal Grant
Name of Grantee

County-District #

Date

Disclosure of Potential Conflict of Interest

Federal grant funds are to be expended for the benefit of the population that the federal grant program serves. Conflicts of interest can arise when
federal grant funds appear to be expended for the primary benefit of some other party.
Identify the expenditure that involves a potential conflict of interest.

Describe in detail how the expenditure was made.

Describe the potential conflict.

Certification
Name and Title of Authorized Official
Signature of Authorized Official

Date

This form must be signed by the authorized official.

Email this signed form to TEA's chief grants administrator at grants@tea.texas.gov.

For TEA Use

Action taken:

Signature of Chief Grants Administrator

Date