Statement of Financial Interests Appeal Form
1. Employee and Position Information
2. Rationale for Statement of Financial Interests Exemption

Reason for receiving the Statement of Financial Interests (specific to reason faculty/staff member received the form):
1. You were listed as the primary or secondary manager for a SAP cost center;
2. You were awarded a Research Grant and/or a Fellowship Award for academic year 2021; and/or
3. You were a department chair for the 2020/2021 academic year and/or the 2021/2022 academic year;
4. You were responsible for at least one of these actions concerning administering, contracting or procurement, zoning, inspecting, licensing or regulating.
5. You were issued a P-Card.
0/200 words
0/375 words
Employee's Signature * 🛈
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KUTZTOWN UNIVERSITY
15200 KUTZTOWN ROAD, KUTZTOWN PA 19530
610-683-1353