Name of Regional Center: ___________________________________

CONFLICT OF INTEREST STATEMENT FOR CPP FUNDING

Name of HDO: ____________________________________ Title: ___________________

I have read and understand Title 17, California Code of Regulations, Chapter 3, Subchapter 3,

Article 1, upon which I declare under penalty of perjury:

(Name of HDO) _______________________________________ and its officers, directors, shareholders, owners and employees have no personal, business, or financial interests, or relationships, with (Name of Regional Center) _____________________________________ or its officers, directors or employees, that would cause a reasonable person with knowledge of the relevant facts to question (Name of HDO) _____________________________________or

(Name of Regional Center) _____________________________________’s impartiality resulting from (Name of Regional Center) _____________________________________’s engagement of (Name of HDO) _____________________________________ to provide CPP services to

(Name of Regional Center) _____________________________________ and its consumers.

Based on the above statement, no present or potential conflict of interest exists between (Name of HDO) __________________________________________ and

(Name of Regional Center) __________________________________________.

________________________________	_________________________

Signature/Title	Date

Received by:

Name of Regional Center: _______________________________________

Signature: _________________________________

Name: ___________________________________

Title: ____________________________________