DISCLOSURE BY ELECTED STATE OFFICIAL OF FINANCIAL INTEREST SHARED WITH SUBSTANTIAL SEGMENT OF THE PUBLIC AS REQUIRED BY 930 CMR 6.25(3)(a) ELECTED STATE OFFICIAL INFORMATION Your Name Your position Your district Population of your district Office address Office phone Office e-mail I am filing this disclosure because I am an elected state official, and I will participate in a particular matter that involves a determination of general policy. My immediate family member and/or I have a financial interest in the matter which is shared with at least 10% of the population of the district that I represent and is the same in nature as those constituents’ financial interests. PARTICULAR MATTER INVOLVING A DETERMINATION OF GENERAL POLICY Particular matter Please describe the particular matter involving a determination of general policy. involving a determination of general policy PARTICIPATION IN THE PARTICULAR MATTER Participation in the Please describe the task you will perform with respect to the particular matter. particular matter E.g., discussion, approval, disapproval, decision, vote, recommendation, advice, investigation, other. FINANCIAL INTEREST IN THE PARTICULAR MATTER Person who has the Do you or an immediate family member have a financial interest in the matter? financial interest ___ Myself Check off all that apply ___ Immediate family member PLEASE PROVIDE THE RELATIONSHIP NOT THE NAME OF THE IMMEDIATE – – FAMILY MEMBER.
DISCLOSURE BY ELECTED STATE OFFICIAL OF FINANCIAL INTEREST SHARED WITH SUBSTANTIAL SEGMENT OF THE PUBLIC AS REQUIRED BY 930 CMR 6.25(3)(a) ELECTED STATE OFFICIAL INFORMATION Your Name Your position Your district Population of your district Office address Office phone Office e-mail I am filing this disclosure because I am an elected state official, and I will participate in a particular matter that involves a determination of general policy. My immediate family member and/or I have a financial interest in the matter which is shared with at least 10% of the population of the district that I represent and is the same in nature as those constituents’ financial interests. PARTICULAR MATTER INVOLVING A DETERMINATION OF GENERAL POLICY Particular matter involving a determination of general policy Please describe the particular matter involving a determination of general policy. PARTICIPATION IN THE PARTICULAR MATTER Participation in the particular matter E.g., discussion, approval, disapproval, decision, vote, recommendation, advice, investigation, other. Please describe the task you will perform with respect to the particular matter. FINANCIAL INTEREST IN THE PARTICULAR MATTER Person who has the financial interest Check off all that apply Do you or an immediate family member have a financial interest in the matter? ___ Myself ___ Immediate family member PLEASE PROVIDE THE RELATIONSHIP – NOT THE NAME – OF THE IMMEDIATE FAMILY MEMBER.
inst-6-25-elected-state-officials-rev-4-1-15.docx