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HomeMy WebLinkAboutCOM 0633.003 2020-2022 M`r oc k� Mitchell D.Roth {tl" ;# Deanna S. Sako Mayor Director Steven A.Hunt Deputy Director County of Hawaii Finance Department I 25 Aupuni Street,Suite 2163 • Hilo,Hawaii 96720 (808)961-8234 Fax(808)961-8569 March 14, 2022 Ma1le Medetros David, Council Chair and Members of the Hawaii County Council Hawaii County Council 5 " 25 Aupuni Street Hilo, Hawaii 96720 ' Re: Nonprofit Grant Applications 'J This is to transmit reprinted Organization Conflict Disclosure Forms for the Boys & Girls Club of the Big Island, Center for Getting Things Started, Educational Services Hawaii Foundation dba EPIC Foundation, Hawaii Children's Action Network, Hawaii Island Home for Recovery, Inc., Holualoa Foundation for Arts & Culture, and Legal Aid Society. The Organization Conflict Disclosure Form and Certificate of Understanding for La`i6pua 2020 is also being transmitted. These organizations submitted their online applications timely and accurately, however in the process of printing the Conflict Disclosure Form and Certificate of Understanding for these applicants, check marked boxes stating no conflict of interest, conflict of interest mitigation measures and/or digital signatures were not included in the printed hard copy. Per our discussion with the office of Council Member Susan Lee Loy, Human Services & Social Services Committee (HSSSC) Chair, and in compliance with Chapter 2, Article 25 of the Hawaii County Code, I am submitting reprinted copies of these documents to include the applicable information. i Should you have any questions,please feel free to call Kelsey Kalua-Lewis at 961-8974 or Lisa Tada at 961-8489. Deanna S. Sako Director of Finance Enc. Conflict Disclosure Forms for Boys & Girls Club of the Big Island, Center for Getting Things Started, Educational Services Hawaii Foundation dba EPIC Foundation, Hawaii Children's Action Network, Hawaii Island Home for Recovery, Inc., H61ualoa Foundation for Arts & Culture, and Legal Aid Society. Conflict Disclosure Form and Certificate of Understanding for La`i6pua 2020 Comm. �lg. Hawaii County is an Equal Opportunity Employer and Provider Ref. Date MAR 1 4 � �� s 4 County of i`i Nonprofit Grant Application Agency Name: Boys & Girls Club of the Big Island Program Name: "Daily Meal Support for Income-Challenged Youth and Familles" i ORGANIZATION CONFLICT DISCLOSURE FOR Please disclose any conflicts or potential conflicts of interest that any board member,officer,director, or administrator of your organization may have with the County of Hawaii.Only those listed below need to be disclosed.One form 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 trust be signed regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship,with any of the following(check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel,the Assistant Corporation Counsel,or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will 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 conflicts or potential conflicts of interest: { Q If no conflicts exist, check here. Signature of Authorized Person (specify title) Date County of `i Nonprofit Grant Application -2 Agency Name: Boys & Girls Club of the Big Island Program Name: "Daily Meal Support for Income-Challenged Youth and Families" ORGAN17ATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member,officer,director, or administrator of your organization may have with the County of Hawaii.Only those listed below need to be disclosed.One form 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 must be signed,regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship,with any of the following(check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel,the Assistant Corporation Counsel,or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by on individual will 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 conflicts or potential conflicts of interest: xQ If no conflicts exist, check here. J Signature of Authorized Person (specify title) Date County of a i`i Nonprofit Grant Application FY 2022-23 Agency Name: Boys & Girls Club of the Big Island Program Name: "Daily Meal Support for Income-Challenged Youth and Families" ORGANIZATION CONFLICT DISCLOSURE FOR Please disclose any conflicts or potential conflicts of interest that any board member,officer,director, or administrator of your organization may have with the County of Hawai`l.Only those listed below need to be disclosed.One form 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. AU disclosure forms must be signed,regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship,with any of the following(check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel,the Assistant Corporation Counsel,or a Deputy Corporation Counsel Conflkt of Interest is defined as:a substantial probability that action token by an individual will 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 conflicts or potential conflicts of interest: xQ If no conflicts exist, check here. UM-A46- { Signature of Authorised Person (specify title) Date 1 County of `1 Nonprofit Grant Application FY 2022-23 i Agency Name: Boys & Girls Club of the Big Island i 3 Program Name: "Daily Meal Support for Income-Challenged Youth and Families" 3 ORGANIZATION CONFLICT DISCLOSURE FORM 3 Please disclose any conflicts or potential conflicts of interest that any board member,officer,director, i or administrator of your organization may have with the County of Hawaii.Only those listed below need to be disclosed.One form 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. Alf disclosure forms must be stoned,regardless of whether o conflict exists. NAME: 3 POSITION: I May have a conflict or potential conflict of interest, including any familial relationship,with any of the following(check all that apply): 3 ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director The Director of Finance The Corporation Counsel,the Assistant Corporation Counsel,or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will 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 conflicts or potential I conflicts of interest: i y Q If no conflicts exist, check.here. Signature of Authorized Person (specify title) Date i County of i`i Nonprofit Grant Application - 3 s 3 Agency Name: Boys & Girls Club of the Big Island Program Name: "Daily Meal Support for Income-Challenged Youth and Families" 3 i 3 ORGANIZATION CONFLICT DISCLOSURE FOR 3 Please disclose any conflicts or potential conflicts of interest that any board member,officer,director, I or administrator of your organization may have with the County of Hawai`l.Only those listed below 3 need to be disclosed.One form 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 must be signed regardless of whether a conflict exists. NAME: POSITION: 1 May have a conflict or potential conflict of interest,including any familial relationship,with any of the following(check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel,the Assistant Corporation Counsel,or a Deputy Corporation Counsel Conflict of interest is defined as:a substantial probability that action taken by an individual will 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 conflicts or potential 3 conflicts of interest: x❑ If no conflicts exist, check here. ULU Signature of Authorized Person (specify title) Date I t s 1 County of `i Nonprofit Grant Application - Agency Name: Boys& Gins Club of the Big Island Program Name: "Daily Meal Support for income-Challenged Youth and Families" 3 ORGANIZATION NFLI DISCLOSURE FOR Please disclose any conflicts or potential conflicts of interest that any board member,officer,director, or administrator of your organization may have with the County of Hawai'i.Only those listed below need to be disclosed.One form 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 must be signed,regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest,including any familial relationship,with any of the following(check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel,the Assistant Corporation Counsel,or a Deputy Corporation Counsel Conflict of interest is defined as:a substantial probability that action taken by an Individual will result in measurable direct benefits accruing to the individual as apposed to benefits accruing in general to an industry. Please specify any and all mitigation measures to avoid, in fact or appearance,any conflicts or potential conflicts of interest: xQ If no conflicts exist, check here. (.../ Signature of Authorized Person (specify title) Date County i`i Nonprofit Grant Application - ................E Agency Name: Boys & Girls Club of the Big Island I Program Name: "Daily Meal Support for Income-Challenged Youth and Families" ORGANIZATION CONFLICT DISCLOSURE FOR Please disclose any conflicts or potential conflicts of interest that any board member,officer,director, or administrator of your organization may have with the County of Hawai`l.Only those listed below need to be disclosed.One form 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. Al!disclosure forms must be signed regardless of whether o conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest,including any familial relationship,with any of the following(check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor The Managing Director The Director of Finance The Corporation Counsel,the Assistant Corporation Counsel,or a Deputy Corporation Counsel Conflict of Interest is defined as:o substantial probability that action token by on Individual will 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 conflicts or potential conflicts of interest: Q If no conflicts exist, check here. 1 i { /} 4 i 1 Signature of Authorized Person (specify title) Date i I i County of `i Nonprofit Grant Application - j Agency Name: Boys & Girls Club of the Big Island Program Name: "Daily Meal Support for Income-Challenged Youth and Families" j ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member,officer,director, or administrator of your organization may have with the County of Hawal'i.Only those listed below need to be disclosed.One form 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 must be stoned regardless of whether a conflict exists. NAME: POSITION: I May have a conflict or potential conflict of interest,including any familial relationship,with any of the following(check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director ❑ The Director of Finance ❑ The Corporation Counsel,the Assistant Corporation Counsel,or a Deputy Corporation Counsel conflict of Interest is defined as:a substantial probability that action taken by an individual will 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 conflicts or potential conflicts of interest: x0 If no conflicts exist, check here. i Signature of Authorized Person (specify title) Date a i`i Nonprofit Grant Application FY 2022-23 genCy Name: Boys & Girls Club of the Big Island i Program Name: "Daily Meal Support for Income-Challenged Youth and Families" ORGANIZATION CONFLICT DISCLOSURE FOR Please disclose any conflicts or potential conflicts of interest that any board member,officer,director, or administrator of your organization may have with the County of Hawaii.Only those listed below need to be disclosed.One form 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. Ali disclosure forms must be signedregardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest,including any familial relationship,with any of the following(check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director The Director of Finance ❑ The Corporation Counsel,the Assistant Corporation Counsel,or a Deputy Corporation Counsel 3 1 conflict of Interest is defined as:a substantial probability that action taken by an individual will 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 conflicts or potential conflicts of interest: i 1 I Q If no conflicts exist, check here. Ulu A� Signature of Authorized Person (specify title) Date i I County of `ifit Grant Application - Agency Name: Boys R Girls Club of the Big Island Program Name: "Gaily Meal Support for Income-Challenged Youth and Families" i-- ORGANIZATION CONFLICT DISCLOSURE FOR Please disclose any conflicts or potential conflicts of interest that any board member,officer,director, or administrator of your organization may have with the County of Hawaii.Only those listed below 3 need to be disclosed.One form 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 must be signed regardless of whether a conflkt exists. NAME; POSITION: I May have a conflict or potential conflict of interest, including any familial relationship,with any of the i following(check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council ❑ The Mayor ❑ The Managing Director (� The Director of Finance s The Corporation Counsel,the Assistant Corporation Counsel,or a Deputy Corporation Counsel 1 I Conflict of Interest is defined as:a substantial probability that action taken by an individual will 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 conflicts or potential conflicts of interest: Q If no conflicts exist,check here. .. o Signature of Authorized Person (specify title) Date i I 4 E t County of awai`i Nonprofit Grant Application FY 2022- 3 Agency Name: Center for Getting Things Started Program Name: Farm to Family ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form 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 must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): Member or members of the Council ❑ Staff appointed by a member of the Council Ej The Mayor ❑ The Managing Director The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will 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 conflicts or potential conflicts of interest: Q If no conflicts exist, check here. I Executive Directorklho�fA-> - 112512022 Signature of Authorized Person (specify title) Date f f t i I County of awai`i Nonprofit Grant Application FY 2022-23 Agency Name: Educational Services Hawai'i Foundation Program Name: 'Imi 'Ike Learning Center at Hilo ORGANIZATION CONFLICT DISCLOSURE FOR Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form 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 must be signed regardless of whether a conflict exists. NAME: Kathie Awaya POSITION: Executive Director May have a conflict or potential conflict of interest, including any familial relationship,with any of the following(check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council The Mayor The Managing Director The Director of Finance The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will 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 conflicts or potential conflicts of interest: Q If no conflicts exist, check here. 1127!2022 Signature of Authorized Person (specify title) Date I i 3 County of awai`i Nonprofit Grant Application FY 2022- 3 Agency Name: Hawaii Children's Action Network (HCAN) Program Name: Hawaii Diaper Bank, a fiscally sponsored program of HCAN ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form 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 must be signed regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): El Member or members of the Council ❑ Staff appointed by a member of the Council i I The Mayor The Managing Director I The Director of Finance I The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel i 3 Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. I Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential conflicts of interest: I I I i j i 3 I 3 I RI If no conflicts exist, check here. I i' i I VP and Executive Director 1120/2022 3 Signature of Authorized Person (specify title) Date 3 3 i A 3 I i 3 County of awai`i Nonprofit Grant Application FY 2022- 3 Agency Name: Hawaii Island Home for Recovery, Inc. HIHR Program Name: HIHR Permanent Supportive Housing Program ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form 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 must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council The Mayor The Managing Director The Director of Finance The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. j Please specify any and all mitigation measures to avoid, in fact or appearance, any conflicts or potential a conflicts of interest: i i x� If no conflicts exist, check here. i 2022101127 Executive Director Signature of Authorized erson (specify title) Date "' i i k County of Hawaii Nonprofit Grant Application FY 2022-23 Agency Name: Hawaii Island Home for Recovery, Inc. HIHR Program Name: HIHR Kitchen & Pantry Outreach Programs ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, I or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form per person with a conflict is needed. If no conflicts exist, one form for j f the organization, with the "No conflicts exist" option checked needs to be submitted. Please duplicate as needed to fully disclose. All disclosure forms must be sinned, regardless of whether a conflict exists. NAME: l POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following(check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council The Mayor The Managing Director The Director of Finance The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will 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 conflicts or potential conflicts of interest: n If no conflicts exist, check here. Executive Director 2022/01/27 Signature of Authoriz Person (specify title) Date I County of Hawaii Nonprofit Grant Application FY 2022-23 I Hawaii Island Home for Recovery, Inc. HIHR Agency Name: Program Name: HIHR Transitional Shelter Program ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form 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 must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship,with any of the following(check all that apply): ❑ Member or members of the Council Staff appointed by a member of the Council I The Mayor The Managing Director The Director of Finance The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will 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 conflicts or potential t conflicts of interest: 4 0 If no conflicts exist, check here. C�J' Executive Director 2022/01/27 Signature of Authorize Person (specify title) Date i County of aai`i Nonprofit Grant Application FY 2022- 3 3 Agency Name: Program Name: 3 a ORGANIZATION CONFLICT DISCLOSURE FORM i I I Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawai'i. Only those listed below need to be disclosed. One form 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 j as needed to fully disclose. All disclosure forms must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): i Member or members of the Council I ❑ Staff appointed by a member of the Council The Mayor The Managing Director The Director of Finance The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will 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 conflicts or potential conflicts of interest: 3 x❑ If no conflicts exist, check here. L fV t Executive Director,Donkey Mill Art Center 1 /30/2022 Signature of Authorized 44on (specify title) Date 7 S�S i County of Flawai`i Nonprofit Grant Application FY 2022- 3 Agency Name: Legal Aid Society of Hawaii Program Name: Providing Civil Legal Access to Rural Communities mom ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form 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 must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council The Mayor The Managing Director The Director of Finance ❑ The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will 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 conflicts or potential conflicts of interest: x0 If no conflicts exist, check here. 113112022 ;i Signature of A ed Person (specify title) Date M. Nalani Fujimori Kaina, Executive Director County of awai`i Nonprofit Grant Application FY 2022-23 Agency Name: Legal Aid Society of Hawaii Program Name: Hawaii Island Medical Legal Partnerships ORGANIZATION CONFLICT DISCLOSURE FORM j Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form 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 must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): ❑ Member or members of the Council ❑ Staff appointed by a member of the Council The Mayor The Managing Director The Director of Finance The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will 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 conflicts or potential conflicts of interest: R If no conflicts exist, check here. Signature of Aut erson (specify title) Date M. Nalani Fujimori Kaina, Executive Director I ,I County of wi`i Nonprofit Grant Application FY 2022-23 Agency Name: La'i'apua 2020 Program Name: Ho'okahua: La`i'opua / Palamanui Culinary Project ORGANIZATION CONFLICT DISCLOSURE FORM Please disclose any conflicts or potential conflicts of interest that any board member, officer, director, or administrator of your organization may have with the County of Hawaii. Only those listed below need to be disclosed. One form 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 must be signed, regardless of whether a conflict exists. NAME: POSITION: May have a conflict or potential conflict of interest, including any familial relationship, with any of the following (check all that apply): xj Member or members of the Council Councilmember- Holeka Goro Inaba ❑ Staff appointed by a member of the Council The Mayor The Managing Director ❑ The Director of Finance The Corporation Counsel, the Assistant Corporation Counsel, or a Deputy Corporation Counsel Conflict of Interest is defined as:a substantial probability that action taken by an individual will 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 conflicts or potential conflicts of interest: I will follow all directions from the County Council to avoid any potential conflicts. ❑ If no conflicts exist, check here. Kawehi Inaba oae:2Oz 02.0916:04:0510'00' 2.9.22 Signature of Authorized Person (specify title) Executive Director Date County of awai`i Nonprofit Grant Application FY 2022-23 Agency Name: La`1`opua 2020 Program Name: Ho`okahua: L2020fPalamanui Culinary Project- Certification rojectCertification of Understanding (Page 1 of 2) 1 (we) have read and understood all of the eligibility requirements; grant conditions; award procedures; and records, reporting, and fiscal accountability requirements as mandated in Article 25, Sections 2- 135—2-142.1, Hawaii County Code, relating to Appropriation of Funds to Nonprofit Organizations. I (we) agree to allow the County(the Legislative Auditor, the Department of Finance, designated Council representative, or expending/oversight agency) full, free, and unrestricted access and authority to examine and inspect any facility, equipment, property, or records pertinent to the grant, contract, or program for which funds were used. I (we) hereby certify that information supplied herein, including all supporting documents, is correct and that I (we) have the authority and ability to fully administer the program(s) pursuant to law. I (we) understand that information supplied herein shall be made public according to Chapter 92F, Hawaii Revised Statutes. I (we) understand that applications will not be reviewed by County personnel receiving our County Nonprofit Grant submittal, and that we have full responsibility to ensure that all documents are complete and accurate prior to submittal. I (we) understand that all documents requiring a current signature must be the ORIGINAL, SIGNED document. Unsigned documents will be disqualified. Faxed or copied documents will not be accepted as original documents. If awarded a grant from the County of Hawaii, I (we) understand and will comply with the requirement to enroll with Hawaii Compliance Express and be compliant prior to receiving payment(s). To register, go to http://vendors.ehawaii.gov, complete the easy step-by-step process, and pay the annual registration fee online using a credit card. If awarded a grant from the County of Hawai'i, I (we) understand and will comply with the requirement to submit a year-end report to the County Council within 60 days after lune 30 of the contractual year for which the grant was awarded. The report, using the template provided,shall include an explanation of the public benefits derived from the awarding of the grant(focusing on specific, measurable outcomes),a complete accounting of all expenditures supported by County of Hawaii grant funds,and a listing of other funding sources and amounts obtained during the award period. Failure to submit a timely, complete, and accurate year-end report, using the template provided, will impact the evaluation of your program's or agency's future funding requests. County of Hawai`z Nonprofit Grant Application FY 2022-23 Agency Name: La`i`opua 2020 Program Name: Ho`okahua: L2020 f Palamanui Culinary Project Certification of Understanding (page 2 of 2) If awarded a grant from the County of Hawaii, I (we) understand that a current Certificate of Liability($1,000,000 general liability, $50,000 each occurrence) must be provided to the County of Hawaii Finance Department, which specifically and explicitly indicates that the County of Hawaii is an additional insured prior to receiving any payment(s). I (we) understand that failure to submit the final report within 60 days of June 301H shall result in loss of all grant funds received during the grant period (must be refunded to County)and exclusion fromfuture grant participation for a minimum of one year or until a written report is submitted to, and accepted by,the council. I (we) understand there is no provision for further notification to submit the final report. Information and instructions are available at http://www.hawaiicounty.gov/fn- nonprofit-grant-forms/on or about May 30 of the year the final report is due. As part of this application, you acknowledge that any funds awarded will be restricted for the purposesstated in the application, except for a maximum ten percent(10l) for administrative and overhead costs. Any funds unused by June 30, 2023 must be returned to the County of Hawaii with the final report. Failure to return these funds in a timely manner will impact the evaluation of Your agency's future funding request and may result in actions taken to recover these funds. Awards cannot provide funds for Capital Improvements(Cost of Construction, materials,insuranceor securities) on private properties unless otherwise authorized by law. i By signing below,you are acknowledging that you have read and understood these requirements. 1 (.� Digitally signed by Ka—hi Inaba January 24, 2021 Kawehi Inaba Nte:2022.01.2516:13:50-10'00' Signature of Authorized Person Date Executive Director Title/Position of Authorized Person