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Agency Name: <br />Program Name: <br />lo. 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 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 />F] No conflicts exist (No further information required. Please sign form at the bottom.) <br />F] 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 />Signature of Authorized Person (specify title) <br />EXHIBIT A <br />NONPROFIT GRANT APPLICATION <br />FY 2013 -2014 <br />Date <br />Page 4 of 7 <br />