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Non-Profit Name: <br /> NON-PROFIT CONFLICT DISCLOSURE FORM <br /> Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, <br /> or administrator of your organization may have with the County of Hawaii. Only those listed below <br /> need to be disclosed. One form per conflict is needed. Please duplicate as needed to fully disclose.All <br /> disclosure forms must be signed, regardless of whether a conflict exists. <br /> NAME: <br /> POSITION: <br /> May have a conflict or potential conflict of interest, including any familial relationship, with any of the <br /> following(check all that apply): <br /> No conflicts exist(No further information required. Please sign form at the bottom.) <br /> Member or members of the Council <br /> _ Staff appointed by a member of the Council <br /> The Mayor <br /> The Managing Director <br /> The Director of Finance <br /> The Corporation Counsel,the Assistant Corporation Counsel,or a Deputy Corporation <br /> — Counsel <br /> Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct <br /> benefits accruing to the individual as opposed to benefits accruing in general to an industry. <br /> Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential <br /> conflicts of interest: <br /> 41"1„/ qm(to/ii / 26 01'1 <br /> Signature of Authorized Person (specify title) Date <br />