HomeMy WebLinkAboutComm. 24-056 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.