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County of Hawaii Nonprofit Grant Application FY2019-20 <br />Agency Name: <br />Program Name: <br />so. ORGANIZATION CONFLICT DISCLOSURE FORM <br />Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, <br />or administrator of your organization may have with the County of Hawaii. Only those listed below <br />need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for <br />the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate <br />as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. <br />NAME. <br />POSITION: <br />May have a conflict or potential conflict of interest, including any familial relationship, with any of the <br />following {check all that apply}: <br />❑ Member or members of the Council <br />❑ Staff appointed by a member of the Council <br />❑ The Mayor <br />❑ The Managing Director <br />❑ The Director of Finance <br />❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation <br />Counsel <br />Conflict of Interest is defined as. a substantial probability that action taken by an individual will result in measurable direct <br />benefits accruing to the individual as apposed to benefits accruing in general to an industry, <br />Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential <br />conflicts of interest: <br />If no conflicts exist, check here. <br />Signature of Authorized Person (specify title) <br />F <br />Date <br />NONPROFIT GRAFT APPLICATION FY 2019-2020 Page 5 of <br />