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 2019; and/or
3. You were a department chair for the 2018/2019 academic year and/or the 2019/2020 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 Kutztown University 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