ࡱ> SUR bjbjWW .R55 PPPPPdddddddddd???$w)$P??$PPdd9zzzPdPdzzzzdp9:zO0zRzPzp?Z@z4 ???$$X"???????????? : DISCLOSURE BY NON-ELECTED STATE EMPLOYEE OF FINANCIAL INTEREST AND DETERMINATION BY APPOINTING AUTHORITY AS REQUIRED BY G. L. c. 268A, 6 STATE EMPLOYEE INFORMATIONName:Title or Position: State Agency:  Agency Address: Office Phone:Office E-mail: My duties require me to participate in a particular matter, and I may not participate because of a financial interest that I am disclosing here. I request a determination from my appointing authority about how I should proceed. PARTICULAR MATTERParticular matter E.g., a judicial or other proceeding, application, submission, request for a ruling or other determination, contract, claim, controversy, charge, accusation, arrest, decision, determination, or finding. Please describe the particular matter. Your required participation in the particular matter: E.g., approval, disapproval, decision, recommendation, rendering advice, investigation, other. Please describe the task you are required to perform with respect to the particular matter. FINANCIAL INTEREST IN THE PARTICULAR MATTERWrite an X by all that apply.  ___ I have a financial interest in the matter. ___ My immediate family member has a financial interest in the matter. ___ My business partner has a financial interest in the matter. ___ I am an officer, director, trustee, partner or employee of a business organization, and the business organization has a financial interest in the matter. ___ I am negotiating or have made an arrangement concerning future employment with a person or organization, and the person or organization has a financial interest in the matter. Financial interest in the matter Please explain the financial interest and include a dollar amount if you know it. Employee signature:Date: DETERMINATION BY APPOINTING OFFICIAL APPOINTING AUTHORITY INFORMATIONName of Appointing Authority: Title or Position:  Agency/Department: Agency Address: Office Phone: Office E-mail DETERMINATION Determination by appointing authority: Write an X by your selection. As appointing official, as required by G.L. c. 268A, 6, I have reviewed the particular matter and the financial interest identified above by a state employee. ___ I am assigning the particular matter to another employee, or ___ I am assuming responsibility for the particular matter, or ___ I have determined that the financial interest is not so substantial as to be deemed likely to affect the integrity of the services which the Commonwealth may expect from the employee. Appointing Authority signature: Date:Comment:   Attach additional pages if necessary. File copy with: State Ethics Commission, One Ashburton Place, Room 619, Boston, MA 02108 Form Revised February, 2012 >?       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