5-Attachment 7 Financial Interests and Potential Conflict of Interests.pdf

ATTACHMENT NO. 7

FINANCIAL INTERESTS AND POTENTIAL CONFLICTS OF INTERESTS

Texas Local Government Code Chapter 176 requires that vendors desiring to enter into certain contracts with a local governmental entity must disclose the financial and potential conflict of interest information as specified below.

Vendor shall disclose the financial interest and potential conflict of interest information identified in Sections one (1) through three

(3) below as a condition of receiving an award or contract. Submit this information along with your bid, proposal, or offer. This form must be received by HCC Office of Systemwide Compliance before the vendor’s bid, proposal, or offer will be considered received or evaluated. Completed forms must be NOTARIZED and delivered to:

This requirement applies to contracts with a value exceeding $50,000.

Section 1 - Disclosure of Financial Interest in the Vendor

a. If any officers or employees of HCC (“individuals”) have one of the following financial interests in the vendor (or its principal) or its subcontractor(s), please show their name and address and check all that apply and (include additional documents if needed):

Name:

Address:

b. For each individual named above, show the type of ownership/distributable income share:

c. For each individual named above, show the dollar value or proportionate share of the ownership interest in the vendor (or its principal) or its subcontractor (s) as follows:

If the proportionate share of the named individual(s) in the ownership of the vendor (or its principal) or subcontractor of vendor is 10% or less, and if the value of the ownership interest of the named individual(s) is $15,000 or less of the fair market value of vendor, check here ( _).

Ownership interest of at least 10% ( ) Ownership interest of at least $15,000 or more of the fair market value of vendor ( ) Distributive Income Share from Vendor exceeding 10% of individual’s gross income ( ) Real property interest with fair market value of at least $2,500 ( ) Person related within first degree of affinity to individual has the following ownership or real property interest in Vendor:

1. Ownership interest of at least 10%

2. Ownership interest of at least $15,000 or more of the fair market value of vendor

3. Distributive Income Share from Vendor exceeding 10% of the individual’s gross income

4. Real property interest with fair market value of at least $2,500

No individuals have any of the above financial interests (If none go to Section 4) ( )

HCC Office of Systemwide Compliance Conflict of Interest Disclosure

If the proportionate share of ownership exceeds 10%, or the value of the ownership interest exceeds $15,000 of the fair market value of vendor, show either:

the percent of ownership %, or the value of ownership interest $ .

Section 2 - Disclosure of Potential Conflicts of Interest For each of the individuals having the level of financial interest identified in Section 1 above, and for any other HCC individual not identified in Section 1 above check "Yes" or "No" to indicate which, if any, of the following potential conflict of interest relationships apply. If "Yes”, please describe (use space under applicable section-attach additional pages as necessary).

a. Employment, currently or in the previous 3 years, including but not limited to contractual employment for services for vendor.

Yes No

b. Employment of individual’s spouse, father, mother, son, or daughter, including but not limited to contractual employment for services for vendor in the previous 2 years.

Section 3- Disclosure of Gifts For each of the individuals having the level of financial interest identified in Section 1 above, and for any other HCC individual not identified in Section 1 above check "Yes" or "No" to indicate which, if any, of the following potential conflict of interest relationships apply. If "Yes”, please describe (use space under applicable section-attach additional pages as necessary).

a. Received a gift from vendor (or principal), or subcontractor of vendor, of $250 or more within the preceding 12 months.

b. Individual’s spouse, father, mother, son, or daughter has received a gift from vendor (or principal), or subcontractor of vendor, of $250 of more within the preceding 12 months.

Section 4- Other Contract and Procurement Related Information

Vendor shall disclose the information identified below as a condition of receiving an award or contract.

This requirement is applicable to only those contracts with a value exceeding $50,000. You must submit this information along with your bid, proposal, or offer.

a. Vendor shall identify whether vendor (or its principal), or its subcontractor(s), has current contracts (including leases) with other government agencies of the State of Texas by checking:

b. If "yes" is checked, identify each contract by showing agency name and other descriptive information such as purchase order or contract reference number (attach additional pages as necessary).

c. Vendor shall identify whether vendor (or its principal) or its subcontractor(s) has pending contracts (including leases), bids, proposal, or other ongoing procurement relationships with other government agencies of the State of Texas by checking:

d. If "yes" is checked, identify each such relationship by showing agency name and other descriptive information such as bid or project number (attach additional pages as necessary).

This disclosure is submitted on behalf of:

(Name of Vendor)

Certification. I hereby certify that to the best of my knowledge and belief the information provided by me in this disclosure statement is true and correct. I understand that failure to disclose the information requested may result in my bid, proposal, or offer, being rejected, and/or may result in prosecution for knowingly violating the requirements of Texas Local Government Code Chapter 176. I understand that it is my responsibility to comply with the requirements set forth by HCC as it relates to this disclosure. I also understand that I must submit an updated disclosure form within seven (7) days of discovering changes in the significant financial interests of the individuals I identified in Section 1 of this disclosure or if individuals that were not identified, later receive a financial interest in my company or is a subcontractor of my company.

Official authorized to sign on behalf of vendor:

Name (Printed or Typed) Title

Signature Date

"NOTE: BIDDER MUST COMPLETE THE ABOVE “FINANCIAL INTERESTS AND POTENTIAL CONFLICTS OF INTERESTS" FORM. FAILURE TO COMPLETE AND RETURN THIS FORM WITH YOUR OFFER SHALL RESULT IN YOUR OFFER BEING CONSIDERED AS "NON-RESPONSIVE" TO

THIS SOLICITATION."

Signed By: ______________________________ Name: ______________________________

Title: ______________________________ State of: ______________________________

Sworn to and subscribed before me at ______________________________ _______________ (City) (State) this ______________________________ day of ______________________________, 20XX

Notary Public of the State of: _____________________________