OFFICE OF THE NEW HAMPSHIRE ATTORNEY GENERAL 
                                CHARITABLE TRUSTS UNIT 
                                33 Capitol Street, Concord, NH 03301-6397 
                                                        
                                MUST BE COMPLETED  
                                AND ATTACHED TO FILING 
 
                                APPENDIX TO ANNUAL REPORT 
 
Name of Organization:______________________________________________________ 
 
1.  Is there currently a conflict of interest policy in effect?    Yes_____     No_____ 
     A Conflict of Interest Policy is required by law. (see RSA 7:19, II) 
 
      If No, please provide explanation for not adopting a Conflict of Interest Policy (attach extra pages 
if necessary): __________________________________________________________ 
 
2.  Did any officer, Director, Trustee, or member of his/her immediate family obtain a pecuniary benefit 
from the organization in the last year other than reasonable compensation for services of an executive 
director, or expenses incurred in connection with his/her official duties? (see RSA 7:19-a) 
      Yes_____     No_____ 
 
If Yes, complete the following: 
 
A.  Was any real estate transaction involved?                      Yes_____     No_____ 
 
B.  Was a loan made to any director, officer or trustee?           Yes_____     No_____ 
 
C.  Was a pecuniary benefit paid in excess of $500?                Yes_____     No_____ 
      If Yes, attach copy of Meeting Minutes. 
 
D.  Was a pecuniary benefit paid in excess of $5,000?              Yes_____     No_____ 
      If Yes, attach a copy of each of the following: 
            Public Notice made pursuant to RSA 7:19-a, II (d) 
            Meeting Minutes 
            Employment Contract 
 
E.  Provide a list of each pecuniary benefit transaction involving a director, officer, trustee or member of 
their immediate family.  Include name(s) of recipient(s) and amount(s) of benefit(s) as required under 
RSA 7:19-a, II (c) and RSA 7:28 (attach extra pages if necessary). 
 
Name of Recipient:_____________________ Nature & Amount of Benefit:________________________ 
 
Name of Recipient:_____________________ Nature & Amount of Benefit:________________________ 
 
NOTE:  The Director of Charitable Trusts may request copies of all contracts, payment records, vouchers and 
financial records or documents involving a director, officer, trustee or member of the immediate family as 
authorized under RSA 7:24. 
Amended 3/15/2013