State Long Term Care Ombudsman Conflict of Interest Form 

You can print the Conflict of Interest Form to complete it  and mail it, or complete it electronically (online) and e-mail it lscharf@ltco.org.

If you are applying to be a Volunteer, please include the Conflict of Interest form with the hard copy of the Volunteer Application. 

If you want to e-mail the Volunteer Application, please sign and mail the Conflict of Interest Form separately to: