Annual Disclosure Statement

Board Members and Officers

Online Form

Member Information
First Name
Last Name
ZIP Code
I serve as a member on the following Board(s) of Directors:
(Choose all that apply.)
Keystone Human Services
Keystone Service Systems, Inc
Keystone Partnership
Key Human Services, Inc.
Keystone Human Services International
Keystone Autism Services

All Board members and Officers of Keystone Human Services, or one its subsidiaries, are required to complete the Annual Disclosure (Conflict of Interest) Statement.

We define a conflict of interest as the opportunity to influence a business decision either directly or indirectly, through one's official position with the company or outside personal interest, which allows for personal gain or may adversely affect the company. As a Board member or Officer of the Organization, you must disclose all actual and/or potential conflicts of interest.

Exceptions and Disclosures

Please provide information on exceptions and/or required or voluntary disclosures in the space below.

If you do not have any exceptions or disclosures to report, please check the box below.

I certify that the information I have provided in responding to the Annual Disclosure Statement is complete and accurate to the best of my knowledge and belief. I further certify that if additional relationships, interest or situations impacting my response to this document should occur, I will promptly notify the Corporate Compliance Officer, Chairman of the Board or President.

For the period of twelve months preceding this disclosure statement and/or for the period since my last disclosure statement, or as a new officer, Board member or Executive of Keystone Human Services, or one its subsidiaries, to the best of my knowledge, with exceptions and disclosures noted, I am in compliance with the provisions of this Annual Disclosure Statement, the Conflict of Interest Policy for Board Members and Officers and the Keystone Human Services Corporate Compliance and Integrity Program.

Board Member/Officer Initials


The undersigned, being an Officer or Board member of Keystone Human Services, or one of its subsidiaries, does hereby certify that to the best of his/her knowledge, he/she is in compliance with the Conflict of Interest Policy and Corporate Compliance & Integrity Program of Keystone Human Services. The overall intent of the policies is to assure that no individual uses their position of trust and authority or his/her access to information or resources in a manner that constitutes either actual or the appearance of self-inurement or conflict of interest that results in personal benefit or the appearance of personal benefit. Essential to this policy is the expectation of full and timely disclosure of all activity that is covered in the policies or other activity that may constitute conflict of interest or give the appearance of impropriety.

Furthermore, the undersigned does hereby disclose all affiliations and relationships with various companies, profit and nonprofit organizations and funders which may have and/or may be perceived as having an impact either directly or indirectly upon the interests of Keystone Human Services, or its affiliates. Any exceptions and/or disclosures are noted in the “Exceptions/Disclosure” section of the attached document.

Principle 4 - Conflicts of Interest

As employees of Keystone Human Services, we work together to meet our common goals. With loyalty and objectivity, we make decisions that affect the company based on the company's best interest–independent of personal or other outside influences. We must never use our positions to profit personally or to assist others in profiting in any way at the expense of the organization.

Keystone recognizes that our employees are involved in many activities outside of their work with the company. A conflict of interest arises when an employee's personal, social, or other activities or relationships have the potential to interfere with the employee's loyalty to Keystone or objectivity in doing business. Your obligation to conduct company business in an honest and ethical manner includes the appropriate handling of actual and apparent conflicts of interest. This sometimes requires that conflicts be avoided altogether, and it always requires full disclosure of any actual or apparent conflicts of interest.

Note: Board members are responsible for adhering to Keystone’s Conflict of Interest for Officers and Directors Policy.

4.1 - Outside Financial Interests

While not all-inclusive, the following will serve as a guide to the types of activities by an employee or household member of an employee that might cause conflicts of interest: 

  • Ownership in or employment by an outside company that does business with Keystone. This does not apply to stock or other investments held in a publicly held corporation, provided the value of the stock or other investments does not exceed 5% of the corporation’s stock.  Keystone may, following a review of the relevant facts, permit ownership interests that exceed these amounts if management concludes such ownership interests will not adversely impact Keystone’s business interest or the judgment of the employee or Board member.
  • Representation of Keystone by an employee in any transaction in which he or she or a household member has a substantial personal interest.
  • Disclosure or use of confidential, special or inside information of or about Keystone, particularly for personal profit or advantage of the employee or a household member.
  • Competition with Keystone by an employee, directly or indirectly or in the purchase, sale or ownership of property or property rights or interests, or business or investment opportunities.

4.3 - Participation on Boards of Directors/Trustees

Occasionally, an employee may be asked to serve on the board of directors, an advisory board or a committee for a profit or non-profit organization.  This can, in some cases, raise a real or apparent conflict of interest or even a legal issue. 

  • An employee must obtain approval from his/her supervisor prior to serving as a member of the board of directors/trustees of any organization whose interests may conflict with Keystone’s.
  • An employee who is asked, or seeks to serve on the board of directors/trustees of any organization whose interest would not impact Keystone (for example, civic, most charitable, fraternal, etc.) will not be required to obtain such approval.
  • All fees/compensation (other than reimbursement for expenses arising from board participation) that are received for board services provided during normal work time shall be paid directly to Keystone (unless the employee uses paid time off to attend the meeting).
  • An employee must disclose all board of directors/trustees activities in the Annual Disclosure Statement.
  • Keystone retains the right to prohibit membership on any board of directors/trustees where such membership might conflict with Keystone’s best interests.
  • Questions regarding whether or not board participation might present a conflict of interest should be discussed with your supervisor.

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