SUPREME HOME HEALTHCARE, LLC DISCLOSURE OF INTERESTS AND CONFLICTS
Pursuant to the purposes and intent of the policy adopted by the Agency,
requiring the disclosure of certain interests and conflicts,
 I hereby state that I have received a copy of the policy and understand that my responsibilities to the agency require that I disclose any duality of interest or possible conflict of interest, for myself and any luelubcr of nlY inl1uediate family, that I

 will not vote or use influence on any matter in which I have a conflict or duality of interest; and will not any accept gifts, favors, or hospitality with any monetary value to comply with this policy. I hereby disclose the following interests and activities of possible conflicts: (Declaration of any Conflict of Interest is listed below and signed in the space provided)