Keystone Solution Center, A Keystone Human Services Initiative Keystone Solution Center

Employee Relationship Statement

Keystone is required to have a current certificate from the Pennsylvania Bureau of Charitable Organizations to solicit contributions. Part of the annual renewal requires Keystone to submit a list of all employee relationships (by blood, marriage or adoption) to any officer, director, trustee, employee or vendor as of the period between July 1, 2006 and June 30, 2007. If you have additional questions, please contact your agency HR Director.

You are required to complete this form by December 14, 2007. The information received is solely for the purposes of meeting our reporting requests and will not be used in any other way.

To make this process as easy as possible, we are asking you to complete this information online. Drop down boxes are provided for additional help.

Employee Information





Relationship Information

I do NOT have any employee OR vendor relationships.

I confirm this information is accurate and correct to the best of my knowledge.
Initial

I have the following relationships. (Please complete areas 1 and/or 2)

The information requested below is to be answered for the time period July 1, 2006 to June 30, 2007.

1. EMPLOYEE to EMPLOYEE Relationships

»View more information about completing this part

A.





B.





C.





D.





2. EMPLOYEE to VENDOR Relationships

»View more information about completing this part

A.






B.






C.






I confirm this information is accurate and correct to the best of my knowledge.
Initial

If you have additional questions, please contact your agency HR Director.

Additional Information

EMPLOYEE to EMPLOYEE Relationships

Please list every employee to whom you are related by blood, marriage or adoption. For each relationship, list the relative, their title, agency and the relationship.

EXAMPLE:

Your sister's daughter, Sally Helper, works for KCMHS as an Intensive Case Manager.

You would complete the information as follows:

Relative's First Name: Sally

Last Name: Helper

Title: Intensive Case Manager

Relative's Agency: Keystone Community Mental Health Services

Relationship: Niece

» Back to top

EMPLOYEE to VENDOR Relationships

Please list every relative who owns a business and is one of our vendors OR who has a prominent position (President, CEO, CFO, Partner, etc.) with one of our vendors.

EXAMPLE:

Your husband, Max Greenhouse, owns a business that is one of Keystone's vendors; your daughter, Sally Greenhouse, is a clerk typist at Capital Blue Cross and your brother's son, Elmer Doe, is a partner at a business with whom we contract.

You would complete the information as follows:

Relative's First Name: Max Last Name: Greenhouse
Relationship: Husband
Business Name: Greenhouse Helpers
Business Address: 123 Side Road
City: Harrisburg
State: PA
Zip: 17101

Relative's First Name: Elmer
Last Name: Doe
Relationship: Nephew
Business Name: Paper, LLC
Business Address: 58 Highway One
City: Harrisburg
State: PA
Zip: 17101

You would not have to complete a section for your daughter, Sally, because she does not have a prominent position within Capital Blue Cross.

» Back to top