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| 40143 | 2015/BrennanTara.pdf | DISCLOSURE BY STATE EMPLOYEE OF FINANCIAL INTEREST IN A CONTRACT TO PROVIDE SOCIAL SERVICES PURSUANT TO 930 CMR 6.07 RECEIVED STATE ETHICS COMMISSION STATE EMPLOYEE INFORMATION Name of state Tara Brennan 2015 JUL 20 AM 10: 25 employee: Title/ Position: Clinical Service Authorization Specialist Agency/Department: Department of Mental Health Agency Address: 167 Lyman Street, Westborough, MA, 01581 Office phone: 508-616-2197 Office e-mail Tara.Brennan@massmail.state.ma.us I am a state employee, and I seek to have a financial interest in a contract or agreement made by a state agency listed below, or by a provider or organization funded by a state agency listed below: A state agency within the following Executive Offices: Executive Office of Health and Human Services, including the Human Service Transportation Office; Executive Office of Public Safety and Security, Executive Office of Elder Affairs, Executive Office of Veteran's Services, or A sheriff's office. The purpose of the contract is: - To provide personal services to a person or persons who receive services from, or have services paid for by, these state agencies; or - To provide educational services to people who work for these state agencies or for providers or organizations funded by these state agencies. I seek approval of the arrangement from the agency for which I serve as a state employee and from the state agency above that made the contract. FINANCIAL INTEREST IN A CONTRACT WITH A STATE AGENCY PLEASE CHECK OFF ONE OF THE THREE STATEMENTS BELOW AND PROVIDE THE REQUESTED INFORMATION. 1) Service to a state agency I will provide personal or educational services to a state agency listed above. Please identify the state agency and also the Executive Office it is in, if applicable. EOHHS 2) Service to a provider or I will provide personal or educational services to a provider or organization funded by a state organization agency listed above. Please provide the name and address of the provider or organization. Advocates Community Counseling 340 Maple St. Marlboro, MA 01702 508-485-9300 Please identify the state agency that funds the provider or organization, and also the Executive Office it is in, if applicable. EOHHS 3) Service to a person or persons I will provide personal services directly to a person or persons who receive services from, or have services paid for by, a state agency listed above. Advocates Community Counseling 340 Maple St. Marlboro, MA 01702 508-485-9300 Please identify the state agency that provides services to, or pays for services for, the person or persons, and also the Executive Office it is in, if applicable. EOHHS Please describe the Please provide information about the type of personal or educational services you will provide. services you will Please do not include the name of any individual who receives services. provide. Fee-for-Service In Home Therapist through CBHI What will you be Please include a dollar amount, if possible. paid, or what other financial interest will $29.00/per hour you have? Employee signature TAO Date: 5/28/15 APPROVAL BY AGENCY YOU SERVE AS A STATE EMPLOYEE Name and title of The Commonwealth of MA appointing authority Department of Mental Health Office phone 508-616-3500 Office e-mail Susan.wing@state.ma.us Signature by By signing here indicate that I have reviewed the facts that the state employee has appointing authority disclosed proposed by the state employee. Shanchury above and approve the arrangement Date: 7-15-15 APPROVAL BY AGENCY THAT MADE THE CONTRACT (IF DIFFERENT) Name and title of person giving approval at the state agency that made the contract Office phone Office e-mail Signature by person By signing here, I indicate that I have reviewed the facts that the state employee has giving approval disclosed above and approve the arrangement proposed by the state employee. Date: Attach additional pages if necessary. File with: State Ethics Commission One Ashburton Place, Room 619 Boston, MA 02108 Form revised February, 2012 |