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Non-Profit Name: Positive Coaching Alliance (PCA) Big Island NON-PROFIT CONFLICT 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. Only those listed below need to be disclosed. One form per conflict is needed. Please duplicate as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: Keith Morioka POSITION: Chair May have a conflict or potential conflict of interest, including any familial relationship, with any of the following(check all that apply): QNo conflicts exist (No further information required. Please sign form at the bottom.) I-1 Member or members of the Council Staff appointed by a member of the Council The Mayor The Managing Director El The Director of Finance flThe 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: Other than the potential conflict of interest described by Director Mason Souza whose sister is a member of the County Council, there is no other conflict of interest. sew-�-a r March 27, 2014 Signature of Autho led P- son (specify title) Date For Use With Requests for Grants from County Council District Contingency Relief Funds. (Form Rev. 9-9-13)