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County of Hawai`i Nonprofit Grant Application FY2019-20 <br /> Agency Name: After-School All-Stars Hawaii <br /> Program Name: After-School at Kau High & Pahala Elementary <br /> 10. ORGANIZATION 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 person with a conflict is needed. If no conflicts exist, one form for <br /> the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate <br /> as needed to fully disclose. All 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 /> ❑ Member or members of the Council <br /> n Staff appointed by a member of the Council <br /> n The Mayor <br /> n The Managing Director <br /> n 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 /> n If no conflicts exist, check here. <br /> ' cr,r) Ptli/ <br /> Signature of Au • ed Person (specify title) Date <br /> EXHIBIT A <br /> NONPROFIT GRANT APPLICATION FY 2019-2020 Page 5 of 8 <br />