COM 0066.002 2022-2024 - Laserfiche WebLink

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County of Ilawail Nonprofit Grant Application FY 2023-24 Agency Name: VASH Hawaii Island Program Name• : VAP v- Visitor Assistant Program COUNTY OF HAWAII DISCLOSURE FORM Please disclose any conflids 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 Hawaiii employee listed below may have with your organization. Only those listed below need to beclisdosed.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 forms must be signed,regardless of 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): El Member or members of the Council Ei Staff appointed by a member of the Council ID The Mayor gi M., p1: e, -The Managing Director .tro.. L.oleo..,) -:p 't..e-c SAAMO 0 The Director of Finance 0 The Corporation Counsel,the Assistant Corporation.Counsel,or a Deputy Corporation Counsel Conflict of Interest is defined es: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 ail mitigation measures to avoid,in fact or appearance,any conflicts or potential conflicts of interest: aLtiA,17 LI aLlk 0 4 \fijc If no conflicts exist,check here. January 18' 2023 Signature of Authorized Person(spedfy title) Date This Form DOES NOT take the place of the requirement that your organization have a conflict of interest clauseholicy within the organization's published rules. This form is to assist the County of Hewer'to avoid potential conflicts of interest during this grant process.