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BOARD OF ETHICS, County of Hawai‘i <br />333 Kīlauea Avenue, 2nd Floor, Hilo, Hawai‘i 96720 <br />Tel. No. (808) 961-8251 <br />GIFTS DISCLOSURE STATEMENT <br /> <br />This statement covers the period from June 1 of the preceding calendar year <br />through June 1 of this year and is due on June 30. <br /> <br />NAME: COUNTY POSITION: <br />COUNTY AGENCY: COUNTY TELEPHONE NO.: <br />COUNTY MAILING ADDRESS: <br /> <br />DONOR DESCRIPTION OF GIFT DATE GIFT AGG. <br />RECEIVED VALUE VALUE <br /> <br />Attach additional sheets if necessary. <br /> <br />CERTIFICATION <br /> <br />I hereby certify that the above is a true, correct, and complete statement. <br />SIGNATURE <br />DATE <br /> <br />Revised 12/10/12 <br /> <br />