COM 0761.001 2022-2024 - Laserfiche WebLink

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County of Hawai`i Nonprofit Grant Application FY 2024-25 Agency Name: Action 4 Animals Hawaii Program Name: The Iris Project COUNTY OF HAWAI'I 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 Hawai'i or that any County of Hawai`i employee listed below may have with your organization. Only those listed below need to be disclosed. 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): ❑ Member or members of the Council n Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director n 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 exist, check here. Jan 22, 2024 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.