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7/9108 <br /> COUNTY OF HAWAI`I <br /> CONTINGENCY RELIEF FUNDS REQUEST <br /> TO: Department of Liquor Control DATE: 1111712025 <br /> Department <br /> FROM: Ashley Kierkiewicz PHONE/FAX: (808) 961-8265 <br /> Council Member <br /> A. REQUEST(ATTACH BACKUP INFORMATION,IF AVAILABLE) <br /> 1. AMOUNT: $1,000 2. TO ACCOUNT#(i.e., 010.500.5503.02): 1010-21-25139-530115 <br /> 3. TO ACCOUNT NAME (i.e., P&R Admin. OCE): Liquor Control-Public Programs, Misc Contract Svcs <br /> 4. PURPOSE(S)OF TRANSFER: To provide support for the Kipuka Farmacy Project in Puna <br /> 5. IF THE MONEY IS DESIGNATED FOR A NONPROFIT ORGANIZATION,NAME OF ORGANIZATION: <br /> 6. IS IT A 501(c)(3)? ®YES ❑ No <br /> *If YES,the IRS determination letter and the Nonprofit Conflict <br /> Puna Community Medical Center Foundation Disclosure Form must be attached to this request form. <br /> 7. COUNTY-RELATED PROGRAM(S)OR ACTIVITY(IES)TO BE FUNDED: To provide support,for the <br /> Kipuka Farmacy Project in Puna <br /> 8. DEPARTMENTAL GOALS AND OBJECTIVES TO BE ADDRESSED: Supporting community-based programs that <br /> that promote education, health,and well-being in drug free, and alcohol free venues. <br /> 9. FUNDING To BENEFIT THE PUBLIC-AT-LARGE(AS OPPOSED TO PRIVATE BENEFIT)? ®YES ❑ NO <br /> 10. IS THE PROGRAM OR ACTIVITY FUNDED ESTABLISHED BY CHARTER,ORDINANCE,OR DIRECTION <br /> OF THE MAYOR? ❑YES ®NO <br /> B. DEPARTMENT'S RECOMMENDATION: DEC 18 202t <br /> ®APPROVE ❑DENY ❑DEFER: <br /> RATIONALE: The Department of Liquor Control supports organizations that enrich the lives of <br /> community members though alcohol free and drug free programs. <br /> I DATE: <br /> Department Head <br /> C. MAYOR'S ACTION <br /> APPROVED ❑DENIED ❑DEFERRED: <br /> COMMENTS: <br /> DATE: DEC 19 <br /> Managing Director Mayor <br />