HomeMy WebLinkAboutConflicts Disclosure Statement-Conflict of Interest-12/14/2016 (5) •
LOCAL GOVERNMENT OFFICER FORM CIS
CONFLICTS DISCLOSURE STATEMENT
(Instructions for completing and filing this form are provided on the next page.)
This questionnaire reflects changes made to the law by H.B. 23, 84th Leg., Regular Session. OFFICE USE ONLY
This is the notice to the appropriate local governmental entity that the following local
government officer has become aware of facts that require the officer to file this statement •Ef t> n
in accordance with Chapter 176,Local Government Code. TEL v E01,
Name of Local Government Officer DEC 1 4 2016
Rachel Huitt, Colleyville Human Resources Director
sCITY SECRETARY'S OFFICF
] Office Held
Name of vendor described by Sections 176.001(7)and 176.003(a),Local Government Code
Holmes Murphy & Associates
JDescription of the nature and extent of each employment or other business relationship and each family relationship
with vendor named in item 3.
Health insurance broker for the City of Colleyville.
.1 List gifts accepted by the local government officer and any family member, if aggregate value of the gifts accepted
from vendor named in item 3 exceeds$100 during the 12-month perioii,described by Section 176.003(a)(2)(B).
Date Gift Accepted 12/15/16 Description of Gift Bowl with chocolate and popcorn.
Date Gift Accepted Description of Gift
Date Gift Accepted Description of Gift
(attach additional forms as necessary)
J AFFIDAVIT
I swear under penalty of perjury that the above statement is true and correct. I acknowledge
that the disclosure applies to each family member (as defined by Section 176.001(2), Local
_ .- -_,.vernment Code) of this local government officer. I also acknowledge that this statement
'' " CHRISTINE LOVEN vers the 12-month period described by Section 176.003(a)(2)(B),Local Government Code.
+' My Notary ID#11092587 -
? of -' Expires May 2,2018
. 11 , /or-14/(A,W.)
Signature of Lo al Government Officer
AFFIX NOTARY STAMP / SEAL ABOVE ..��// �J��//ff 111,L-6-- , ///.{/�, 'Sw rn to and subscribed before me,by the said)/ (� 9 L_ K this the /7/,V day
of G(.acU 20 ! ,to certify whic , itness m hand and seal ice.
16/5-i1 / / 0 ,C.
Signature of officer administering oath Printed name of officer administering oath Title of officer administering oath
Form provided by Texas Ethics Commission www.ethics.state.tx.us Revised 11/30/2015