HomeMy WebLinkAboutDisclosure Form FY 2023-24 11-18-22County of Hawai‘i Nonprofit Grant Application FY 2023-24
Agency Name:
Program Name:
COUNTY OF HAWAI‘I 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 Hawai‘i or that any County of
Hawai‘i employee listed below may have with your organization. Only those listed below need to
bedisclosed. 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:
If no conflicts exist, check here.
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 during this grant process.