Comm. 24-056 - Laserfiche WebLink

Home

Comm. 24-056 PONC Stewardship Grant Application County of Hawai'i Disclosure Form Agency/Nonprofit Organization Name: Stewardship Project Name: Please disclose any conflicts or potential conflicts of interest that and board member, officer, director, or administrator of your organization may have with the County of Hawai'i or that any County of Hawai'i employee listed below may have with your organization. Only those listed below need to be disclosed. One from per person with a conflict is needed. If no conflicts exist, one form for the organization,with the"No conflicts exist"option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms mustbe signed,regardless of whethera conflict exists. Name: Position/Title: May have a conflict of interest or potential conflict of interest, including any familial relationship with any of the following(check all that apply): ❑ A member or members of the County Council; ❑ Staff appointed by a member of the County Council; ❑ The Mayor; ❑ The Managing Director; ❑ The Director of Finance; or ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel. Conflict of interest is defined as a substantial probabilitythat action taken by an individualwill 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 conflict of interest(please also attach a copy of your organization's conflict of interest clause/policy within the organization's published rules): ❑ No conflicts exist Signature of Authorized Person (specify title) Date This form DOES NOT take the place of the requirement that your organization have a conflict of interest clause/policy within the organization's published rules. This form is to assist the County of Hawai i to avoid potential conflicts of interest duringthis grant process.