COM 0066.001 2022-2024 - Laserfiche WebLink

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County of Hawai`i Nonprofit Grant Application FY 2023-24 Agency Name: After-School All-Stars Hawaii Program Name: Academic Enrichment COUNTY OF HAWAII DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member,officer,director, or administrator of your organization may have with the County of Hawaii or that any County of Hawaii employee listed below may have with your organization. Only those listed below need to bedisclosed. One form per person with a conflict is needed. If no conflicts exist,one form for the organization,with the "No conflicts exist"option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure[orms must be signed, regardless oL whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest,including any familial relationship,with any of the following(check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director I I The Director of Finance ❑ The Corporation Counsel,the Assistant Corporation Counsel,or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid,in fact or appearance,any conflicts or potential conflicts of interest: If no conflicts exis - re. Paula Fitzell, Presid a d hire Executive Officer January 6, 2023 Signature of Authorized Person (specify title) Date This Form DOES NOT take the place of the requirement that your organization have a conflict of interest clause/policy within the organization's published rules. This form is to assist the County of Hawai'i to avoid potential conflicts of interest during this grant process.