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 2023; and/or
3. You were a department chair for the 2022/2023 academic year and/or the 2023/2024 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.
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0/375 words
Employee's Signature * 🛈
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OFFICE OF THE CHANCELLOR
2300 VARTAN WAY, SUITE 207, HARRISBURG, PA 17110
KUTZTOWN UNIVERSITY
15200 KUTZTOWN ROAD, KUTZTOWN PA 19530
610-683-1353