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Non - Profit Name: National American Red Cross (aka: American Red Cross, Hawaii State Chapter) <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 Hawai'i. 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:Coralie MatayosY_ <br />POSITION:CEO <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 format 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 />Cho <br />Signature of Authorized Person (specify title) <br />10/1/14 <br />Date <br />For Use With Requests for Grants from County Council District Contingency Relief Funds. (Form Rev. 9 -9 -13) <br />