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Non-Profit Name: Positive Coaching Alliance 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 Hawai'i. 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:Mason A. Souza POSITION: Board Member May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): nNo conflicts exist (No further information required. Please sign form at the bottom.) Member or members of the Council nStaff appointed by a member of the Council The Mayor The Managing Director nThe 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: My sister is County Councilwoman Valerie Poindexter. I am also the Recreation Administrator for the County of Hawaii P&R Recreation Division. Positive Coaching Alliance plays an important role in our youth athletic activities giving our division a partner to work with in providing a safe environment for all. Positive Coaching Alliance also teaches life lessons using sports activities. ■` /1 Signature of Authorized Person (specify title) Date For Use With Requests for Grants from County Council District Contingency Relief Funds. (Form Rev. 9-9-13)