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County of c ,Id wiai'i Nonprofit Grant AppYicati®n FY20 19-2® <br /> Agency Name: ' loha independent Living Hawaii <br /> Program Name: �nd6pendent Living Program <br /> la ®I GANE .T ON' CONFLICT DISCLOSURE FO S <br /> Please disclose any con'lictS or potential conflicts of interest that any board member, officer, director, <br /> or administrator of you 1 or4anization may have with the County of Hawaii. Only those listed below <br /> need to be disclosed. 0 e form per person with a conflict is needed, If no conflicts exist, one form for <br /> the organization,with t' e ",No conflicts exist"option checked needs to be submitted. Please duplicate <br /> as needed to fully disci,se. 11All disclosure forms must be signed, regardless of whether a conflict exists. <br /> NAME: <br /> POSITION: <br /> May have a conflict or 1.tential conflict of interest, including any familial relationship, with any of the <br /> following(check all tha I apply): <br /> ❑ Member .r members of the Council <br /> n Staff app inted by a member of the Council <br /> ❑ The May ll r <br /> ❑ The Man.,ging Director <br /> ii The DireiI or bf Finance <br /> E The Corp 'ration Counsel, the Assistant Corporation Counsel, or a Deputy Corporation <br /> Counsel <br /> Conflict of Interest is define, as:a substantial probability that action taken by an individual will result in measurable direct <br /> benefits accruing to the indi fual?as opposed to benefits accruing in genera!to an industry. <br /> Please specify any and a1 mitigation measures to avoid, in fact or appearance, any conflicts or potential <br /> conflicts of interest: <br /> 0 If no conflicts exi. check here. <br /> r ,% " 4 2, / / .ee 01/25/ •1 9 <br /> iS'ignature of Authorized ,Berson (specify title) Date <br /> EXHIBIT A <br /> NONPROFIT GRANT APPLI a A TION FY 2019-2020 Page 5 of 8 <br />