Act 44 Disclosure Forms
ACT
44
DISCLOSURE
FORM FOR ENTITIES
PROVIDI PROFESSIONAL
SERVICES
TO THE
HOME
RULE
BOROUGH
OF
EDINBORO'S PENSION SYSTEM
CHAPTER
7-A OF
AcT 44 OF
2009
MANDATES
the
annual
disclosure
of
certain
information
by
every
entity (hereinafter
"Contractor")
which
is
a
party
to a
professional
services
contract
with
one
of
the
pension funds
of HOME
RULE
BOROUGH
OF
EDINBORO
(hereinafter
the
"Requesting
Municipality").
Act 44 disclosure
requirements
apply
to Contractors
who provide
professional
pension
services
and
receive payment of
any
kind
from
the
Requesting
Municipality's
pension fund. The
Requesting
Municipality has
determined
that your
company
falls
under
the
requirements
of
Act
44
and
must
complete
this disclosure form. You
are
expected
to
submit
this
completed
form,
to
the
Requesting
Municipality below, by
October
25th,
2011. If,
for
any
reason
you
believe
that
Act
44
does
not
require
you
to
complete
this disclosure form,
please
provide
a
written
explanation of
your
reason(s)
by
September 1st,
2011.
RETURN
COMPLETED
DISCLOSURE
TO:
Home
Rule
Borough
of
Edinboro
Attn: Manager
Taras
Jemetz
124
Meadville
Street
Edinboro,
PA 16412
814-734-1812
X
123
edinboro@edinboro.net
REQUIRED UPDATES:
Where noted,
information
in
this
form
must
be
updated
in
writing
as
changes
occur.
DEFINITIONS
FOR
DISCLOSURE
CONTRACTOR
SUBCONTRACTOR
OR
ADVISOR
AFFILIATED
ENTITY
Any
person,company,
or
other
entity
that
receives
payments, fees,
or any
other form
of
compensation
from a
municipal
pension fund
in exchange
for
rendering
professional
services for
the
benefit
of the municipal
pension fund.
Anyone
who is
paid
a
fee or
receives
compensation from a
municipal pension
system
-directly
or
indirectly from or
through a
contractor.
Any of
the following:
I.
A subsidiary
or
holding company
of
a
lobbying
firm or
other business
entity
owned in whole or
in
part
by
a
lobbying
firm.
2. An
organization
recognized
by
the
Internal
Revenue
Service
as
a tax-exempt
organization under section 501(c)
ofthe
Internal Revenue
Code
of
1986
(Public
Law
99-514,
26
U.S.C.
§
501(c)
)
established
by a
lobbyist
or lobbying
firm or an
affiliated
entity.
-CONTRIBUTIONS POLITICAL
COMMITTEE
EXECUTIVE
LEVEL
EMPLOYEE
MUNICIPAL PENSION
SYSTEM MUNICIPAL
PENSION
SYSTEM
OFFICIALS
AND
EMPLOYEES; MUNICIPAL
OFFICIALS
AND EMPLOYEES
PROFESSIONAL
SERVICES CONTRACT
As
defined
in
section
1621of
the act
of
June
3'd,
1937
(P.L.
1333, No.
320),
known
as the
Pennsylvania
Election
Code
As
defined in
section
1621ofthe act
of June
3'd,1937
(P.L.
1333,
No.
320), known
as
the
Pennsylvania
Election
Code
Any
employee or
person
or
the
person's
affiliated
entity
who:
I.
Can affect
or
influence
the outcome
of the
person's
or
affiliated entity's
actions,policies,
or decisions
relating
to
pensions
and the
conduct
of
business
with a
municipality
or a
municipal pension
system;
or
2.
Is
directly
involved
in
the
implementation
or development policies
relating
to
pensions,investments, contracts or
procurement
or
the
conduct
of
business
with a
municipality
or muni
m.
Any
qualifying
pension
plan,
under Pennsylvania state
law,
for
any municipality
within the Commonwealth
of
Pennsylvania;includes the Pennsylvania
Municipal
Retirement System.
Example:
the
Police
Pension
Plan for
the
Borough
of
Winchesterville
Specifically,
those listed in
TABLE
2
titled:
"List
of
Pension
System and Municipal
Officials
and
Employees"
on the
next
page. Where
applicable,includes
any
employee
of
the
Requesting
Municipality.
A contract to
which
the
municipal
pension
system
is
a party
that is:
(1) for
the
purchase
of professional
services including
investment
services, legal
services,
real
estate
services,
and
other consulting
services;
and,
(2) not
subject to
a requirement
that the lowest bid
be
accepted.
List
of
Municipal
Officials 2011
for
the
Requesting
Municipality
Certain
requests
for
information in
this form
will
refer
to
a
"List of
Municipal
Officials." To
assist
you
in
preparing
your
answers,
you
should
consider
the
following
names
to
be
a
complete
list of
pension system
and municipal
officials
and employees.
Throughout
this
Disclosure
Form,
the
below names
will be
referred
to as
the
"List
of
Municipal
Officials."
Elected
Officials:
Gregory
Lucas-
Mayor
Mary
Ann
Horne-
Deputy
Mayor/ Pension
Committee member Jean
Davis-
Council
member/
Pension
Committee
member Clifford
Allen-
Council
member
Michael
Amidon-
Council
member
John
Austin-
Council
member
Brenda
Cannell-
Council
member/Pension
Committee member
Ritchie
Marsh
-Solicitor
Appointed
Officials
or
Employees:
Taras
Jemetz-
Borough
Manager/
CAO, Pension
Plans
Marie
Lander-
Assistant
to
the
Manager/CAO
Assistant,Pension
Plans
Robert
Kennerknecht-
WWCT
Superintendent/Non
Uniform
DB
Pension
Committee member
Victoria
Coffin-
Clerk/
Non
Uniform
DB
Pension
Committee
member
John
Groh-
Code
Enforcement Officer/
Non
Uniform
DC
Pension
Committee member
Doug
Bennett-
Water
Department
Operator/Non
Uniformed
DC
Pension
Committee
member
John
Beuchert-
Police
Officer/Police
DB
Pension
Committee
member
Jeffrey
Craft-
Police
Chief-
Police DB
Pension
Committee member
IDENTIFICATION
OF
CONTRACTORS &
RELATED
PERSONNEL
CONTRACTORS:
(See "Definitions"
-page
2)
Any
entity
who
currently
provides
service(s)
by means
of
a Professional Services
Contract
to
the
Municipal Pension
System
of
the
Home
Rule Borough of
Edinboro (Requesting
Municipality),
please
complete
all
of
the
following:
Identify
the
Municipal
Pension
System(s)
for
which
you
are
providing information:
Indicate all
that
apply
with
an
"X": NonUniform
DB
Plan
0 Police
DB
Plan
D Non Uniform
DC
Plan
**NOTE:
For all
that
follow,
you
may
answer
the
questions
I
items on
a
separate
sheet
of
paper
and attach
it
to this
Disclosure if
the
space
provided
is not
sufficient.
Please
reference
each
question
I
item
you are
responding
to
by
the
appropriate
number.
(example:
REF-
Item
#1.)
1. Please
provide
the
names
and
titles
of
all
individuals
providing
professional
services
to
the
Requesting Municipality's pension
plan(s)
identified above. Also
include
the
names
and
titles
of any
advisors
and
subcontractors
of
the
Contractor, identifYing
them as
such. After
each
name
provide
a
description of
the responsibilities
of
that
person
with
regard
to
the
professional services
being
provided
to
each designated pension
plan.
William
C. Asay,
CEBS
-
President
&
CED -
Consultant
fuvid
H.
Stimpson, E.A.,
M.A.A.A.
-
Vice President
of
Actuarial
Services
G.
Herbert
I.ocmis,
F.S.A.,
E.A.A.A.,
M.A.A.A.
-
Consulting
ActtJalj
Zac.haryyKii:kpatrick-
Actuarial Analyst
2.
Please
list
the
name
and
title
of
any
Affiliated
Entity
and
their
Executive-level
Employee(s) that
require disclosure;
after
each
name,
include
a
brief
description
of
their
duties.
(See:
Definitions)
None
3.
Are
any
of
the
individuals
named
in
Item
1
or
Item
2
above,
a
current
or
former
official
or
employee
of
the
Requesting
Municipality?
l\IJ
...
IF "YES",
provide
the
name
and
of
the
person
employed, their
position
with
the
municipality,
and dates
of employment.
4. Are
any
of
the
individuals named
in
Item 1
or
Item
2
above a
current
or
former
registered
Federal
or
State lobbyist? NO
...
IF "YES",
provide
the
name
of
the
individual,
specifY
whether
they
are
a
state
or federal
lobbyist,
and
the date
of their
most
recent
registration
/renewal.
5.
Since
December
171h
2009,
has
the
Contractor
or
an
Affiliated Entity paid compensation
to
or
employed any
third party
intermediary,
agent,
or
lobbyist
that is
to
directly
or
indirectly
communicate with
an
official
or employee
of
the
Municipal
Pension
System
of
the
Requesting
Municipality
(OR),
any
municipal
official or employee
of
the
Requesting
Municipality in
connection
with
any
transaction or
investment
involving
the Contractor
and
the
Municipal
Pension
System
of
the
Requesting
Municipality? No
This
question does
not
apply
to an
officer
or
employee
of
the Contractor
who
is
acting
within
the
scope of the
firm''s standard
professional duties
on
behalf
of
the
firm,
including
the
actual
provision
of
legal, accounting, engineering,
real
estate,
or
other
professional
advice,
services,
or
assistance pursuant
to
the professional
services
contact
with
municipality's pension
system.
-+
IF
"YES",
identify: (1)
whom
(the
third
party
intermediary, agent,
or
lobbyist) was paid
the
compensation
or employed
by the Contractor
or
Affiliated
Entity,
(2)
their
specific
duties
to
directly
or
indirectly
communicate
with
an
official
or
employee
of the
Municipal Pension
System
of
the
Requesting
Municipality
(OR),
any
municipal
official
or
employee
of the Requesting
Municipality, (3)
the
official
they
communicated with,
and
(4)
the
dates
of
this
service.
6. Since
December
17"'
2009,
has
the
Contractor, or
any
agent,
officer,
director
or
employee
of
the
Contractor solicited
a
contribution
to
any
municipal officer or
candidate
for
municipal
office
in
the
Requesting Municipality,
or
to the
political party
or
political
action committee
of
that
official
or
candidate? 110
-+
IF "YES", identify the
agent, officer,
director
or
employee
who
made
the
solicitation
and
the
municipal
officials, candidates,
political
party
or
political
committee
who
were
solicited
(to
whom
the
solicitation
was
made).
7. Since
December
17'',
2009:
Has
the
Contractor
or an
Affiliated
Entity
made
any contributions
to
a municipal
official
or
any candidate
for
municipal
office
in
the
Requesting
Municipality?
NO
-+
IF "YES", provide
the
name
and
address
of
the person(s) making the
contribution, the contributor's
relationship
to
the
Contractor, The
name and
office
or
position
of
the
person
receiving
the
contribution
,
the
date of
the
contribution, and
the
amount
of the
contribution.
8. Does
the
Contractor
or
an
Affiliated
Entity
have
any
direct
financial, commercial
or
business
relationship with
any
official
identified
on
the
List of
Municipal
Officials, of
the
Requesting
Municipality? NO
-+
IF "YES",
identify the
individual
with
whom
the
relationship
exists
and
give
a
detailed
description of
that
relationship.
**NOTE:
A
writteQ
letter is
required from
the
Requesting
Municipality acknowledging
the relationship and
consenting
to
its
existence.
The
letter
must
be
attached
to this disclosure.
Contact
the
Requesting
Municipality
to
obtain
this
letter
and
attach
it
to
this
disclosure before submission.
9.
Has
the
Contractor
or an
Affiliated Entity
given
any
gifts
having
more
than a
nominal
value
to any
official, employee
or
fiduciary
-
specifically,
those
on
the
List
of Municipal
Officials
of
the
Requesting
Municipality?
NO
-+
IF "YES",
Provide the
name
of
the
person
conferring
the
gift,
the
person
receiving the
gift,
the
office
or
position
of the
person
receiving
the
gift,
specify
what
the gift
was,
and
the
date
confetTed.
10.
Disclosure
of
contributions
to
any
political
entity
in
the
Commonwealth
of
Pennsylvania Applicability:A
"yes"
response
is
required
and
full
disclosure is
required
ONLY
WHEN ALL
of the
following
applies: None ·
a)
The
contribution was
made
within
the last
5
years
(specifically since:December
18th
2004)
b) The
contribution was
made by
an
officer,
director, executive-level
employee
or
owner of
at
least
5%
of
the
Contractor
or
Affiliated
Entity.
c)
The
amount
ofthe
contribution was
at least
$500
and in
the
form
of:
1.
A single
contribution
by
a
person
in (b.)
above,
OR
2.
The
aggregate of
all
contributions all
persons
in (b.)
above;
d)
The
contribution was
for
1.
Any
candidate
for
any.public
office
or
any
person
who
holds an
office
in
the
Commonwealth of Pennsylvania;
2.
The
political committee
of
a
candidate
for
public
office
or
any person
that
holds
an
office
in
the Commonwealth
of
Pennsylvania.
-+ IF
"YES",
provide
the
name and
address
of
the
person(s)
making
the
contribution, the
contributor's relationship
to
the
Contractor,
The name
and
office
or
position
of
the person
receiving
the
contribution
(or
the political
entity
I
party
receiving
the
contribution),
the
date
ofthe
contribution,
and
the
amount
of
the contribution.
11. With
respect
to your
provision
of
pt•ofessional
services
to
the
Municipal
Pension
System
of
the
Requesting
Municipality:
Are you
aware
of
any
apparent,
potential
or
actoal
conflicts
of
interest
with
respect
to
any officer,
dit-ector
or
employee of
the
Contractor
and officials
or
employees
of
the
Requesting
Municipality? NO NOTE:
If,in
the
future,
you
become
aware of
any
apparent,
potential,
or
actoal
conflict
of
interest, you are
expected
to
update
this
Disclosure
Form
immediately
in
writing
by:
•
Providing
a
brief synopsis
of
the
conflict
of
interest
(and);
·
•
An
explanation
of
the steps
taken
to address this
apparent,
potential, or
actual
conflict
of
interest.
-+
IF
"YES",
Provide
a
detailed
explanation of the
circumstances
which
provide
you
with
a
basis to
conclude
that
an apparent,
potential,
or
actual
conflict
of
interest
may
exist.
12. To
the
extent
that
you
believe
that
Chapter 7-A
of Act
44
of
2009
requires
you to
disclose
any
additional information
beyond
what
has
been
requested above, please
provide
that
information
below
or
on
a
separate piece
of paper.
None
Please
provide the
name(s)
and
position(s)
of
the
person(s)
participating
in the
completion
of
this
Disclosure. One
of the
individuals
identified
by
the
Contractor
in
Item #1
above
must
participate
in
completing
this Disclosure
and
must
sign
the
below verification
attesting
to
the
participation
of those individuals
named
below.
Name:
William
c.
Asay,
CEBS
Name: Position:
President &
00
Position:
Name:
Name:
Position:
Position:
Name:
Name: Position:
Position:
President
&
00
TITLE
July 21,
2011
DATE
I,
_:William::o· ·==-.:::C•c-.:.:Asa=.Y
,
hereby state
that
I
am
..:Th.:.:es
iden=;;t;::..=&'<-'CED==--------
(Name)
(Position)
for
---,""'""-fu:kenha.,...-,-.,..,.,...,--u::..pt_Ben_ef_i_ts_G_ro_u::..p
,and
I
am
authorized to
make
this
verification. (Contractor)
I hereby
verify
that
the
facts
set
forth
in
the
foregoing
Act
44
Disclosure Form
for
Entities
Providing Professional
Services
to
HOME
RULE
BOROUGH
OF
EDINBORO
Pension System
are
true
and correct
to the
best of
my
knowledge, information
and
belief.
I
also
understand
that
knowingly
making material misstatements
or
omissions
in
this form
could
subject
the
responding
Contractor
to
the penalties in
Section
705-A(e)
of
Act
44.
I
understand
that
false
statements
herein
are
made
subject
to
the
penalties
of
18
P.A.C.S. §
4904 relating to
unsworn
falsification to
authorities.
Signature
ACT
44
DISCLOSURE
.FORM FOR
ENTITIES
PROVIDING PROFESSIONAL
SERVICES
TO
THE
HOME RULE
BOROUGH
OFEDINBORO'SPENSION
SYSTEM
CHAPTER
7-A
OF
AcT.44
OF 2009
MANDATES
the
annual
disclosure
of
certain information
by
every
entity (hereinafter
'!Contractor")
which
is
a
party
to a
professional
serVices
.contract
with
one
ofthe.
pension funds oflloME RuLE
BoRoUGH
QF
EDI\'II!ORO
(hereinafter
tlw
·
tequ¢sting
Municipality''); Act
44 dis.closu.re
requirements
apply
to
Contrar;tors
who
provide
professional pension
services
and
receive payment
of any
kind
from the
Requesting
Municipality's
pension
fund; The Requesting
Municipality has
determined that
yow
.company
falls
under
the
requirements
of
Act 44
and
must.
complete
this discloswc:
form.
Yquare
expected
to
submit
this
completed
form,
to
the
Requesting
:M;unicipalitybelow, by
Oct6ber
25th,
2011.
If,
for
any
reason
you believe that
Act
44
does
not
require
you
to
complete this disclosure
form,
please provide a
written.
explanation.of
youneason(s)
l;ly
September
1st,
2011.
RETURN
COI\Ill'!lETED
DISCLOS.URE
TO:
Home
Rcile
B.orougli.of
Edlttbilro
Alttt: Manager
T11ras
Jemetz
14
Meotdvifle
Street
Edinboro, l'A i64l2
814-734-1812
X
123
edinboro@edinboro.net
REQUIRED UPDATES:
Where noted,
information
in this
form
must
be
updatedin
writing
as
changes
oco)lr.
1
Any
person,
company,
or
other
entity
that
receives
payments,
fees,
or any
other form
of
compensation
from
a
municipal
pension fund.
in exchange
for
rendering
professional
services
forth
e. benefit
of
the municipal
pension
fund.
Any one who is
paid
a fee
or
receives
compensation
from
a
municipal pension
system
-directly
or
indirectly
from
or
through
a
contractor.
Any
of the
following:
I.
Asubsidiary
or
holding
company
of a
lobbying
firm or other business entity
owned in Whole
or in
part by a
lobbying
firm.
4. An
organization
recognized
by
the
lnternal.Revenue
Service
as a tax·exempt
organization
under
section
5Q1(c)
of
the
Internal Revenue
Code
of
1986
(Public
Law
99-514,
26
U.S.C.501(c))
established
by a
lobbyist
or firm
or
an
affiliated
entity.
As·
defined
in
section
1621of
the act
of
June
3'd,
1937
(P.L.1333,
f\Jo'
320), known
as the
Pennsylvania
Election
Code
As
defined in
section
1('i21ofthe
act
of
Juhe3'd,
1937
(P.L.1333,
No.
320),
known
as the
Pennsylvania
Election Code
Any
employee
or person
or
the person's affiliated
entity
who:
L
Can
affect
or
influence the outcome of the
person's
or
affiliated entity's actions,
policies,
or
decision relating to
pensions
and the
conduct
of business
with
a
municipality or
a
municipal
pension
system; or
z. Is
directly
involved
in
the
implementation
or
development
policies
relating
to
pensions,
investments,
contracts
or
procurement
or the
conduct
of
business
With
a
municipality or
Any
qualifying pension
plan,
underPE:!nnsylvania statE:!
law,
for
any municipality within
the
Commonwealth
of
Pennsylvania; includes.
the Pennsylvania
Municipal Retirement
System.
(;xatnpl
:
the
Pollee:
Pension Ptrm[or
the
f3orough6f
Wincnesterville
Silecifii:alhl.
those
listed in
TABLE
2
titled:
"List
of
Pension System
and Municipal
Officials and
Employees"
on
the
next
page.
Wher.e applicable,
includes
any
employee
ofthe Requesting
Municipality.
A
contract
to which
the
municipal pension
system
is
a party
that
is:
(1) forthe
purchase of
professional
services
including
investment
services, legal
services,.real
estate
services,
and.
other consulting
services; and, (2)notsubject
to
a
requirementthat
the
lowest
bid
be
.accepted.
List
.of
Municipal
Officials
2011for
the
Requesting
Municipality
Ce1tainrequests
for
information
irt
this
form
will
refer
to a
"List
of
Municipal
Officials.'' To
assist
you
in
preparing your
answers,
you
should
consider
the
following
names
to be.
a
complete list
of pension
system
and
municipal
officials
and employees.
Throughout
this
Disclosure
Form,
the below
names
will
be
referred
to
as
the"List of
Municipal
Officials.''
Elected· Officials:
Gregory Lucas, Mayor
Mary
Ann Horne
-
Deputy
Mayor/ Pension
Committee
member
Jean
Davis-
Council
member/
Pension
Committee
member
Clifford
Allen-
Council
member
Michael
Amidon- Council
member
John
Austin- Council
member
Brenda Cannell-Council
member/Pension
committee
member
Ritchie Marsh
•
Solicitor
Appointed
Officials
or
Employees:
Taras
Jemetz-
Borough
Manager/
CAO,Pension
Plans
Marie
Lander-
Assistant
to
the Manager/CAO
Assist<;1nt,Pension
Plans
Robert Kennerknecht-
WWCT Superintendent/Non
Uniform
DB
Pension
Committee member
Victoria Coffin-
Clerk/
Non
Uniform oil.
Pension
Committee
member
John
Groh-
Code
Enforcement Officer/
Non Uniform DC
Pension Committee
member
Doug
Bennett-
Water
Department Operator/Non
Uniformed
DC
Pension
Committee
member
John
Beuchert-
Police
Officer/Police
DB Pension
Committee
member
Jeffrey Craft-
Police Chief
-Police
DB
Pension
Committee
member
IDENTIFICATION
OF
CONTRACTORS&RELATED
PERSONNEL
CONTRACTORS:
(S.ee
"Definitipn$"-page
2)
.A,rjy
entity
who
currently provides
serv!ce(s) by
means
ofa Professiol)al
Services
(Jpntract!o the
Municipal
P nsion System
of
the
Home
Rule
!3orough
of
Edinboro (Requ
stlngMuni ipallty),
please
complete
all
of!he
following;·
Identify tire.
Mnnieipal
en$lon
System(s) for
which
yo11.are
proyidingJnt'QI"m>
tion:
I11dicate
llllthatapply
with an
''X:'':
I )(
INontJniforiJI D,B
Plan
I
)( J
Police
I>:B
Plan
[XJNon
U)liformDO
Plan
**NOTE:
For all
that
follow,
you may
answer
the
questions
I
items
on a
sep
ate
sheet
0fpaper
and attach
it to
this
Disclosuteifthe
space provided
is
not
sufficient..
Please
reference
each question/
item you
are
responding
to
by the
appropriate
number.
{example:
REF
-Item
#1.)
l.
Pleasec
provide the
names ancl
titles
of
all
individuals
prQviding professional
services
to
the
RequesJing
Municipality's
pension
plan(s)
identified
above.
Alsoinclude the
names
and
tiiies
of
any
advisors
and
.subcontractors
of !he
Contractor,
iClentitying the111
as
such..
After.
each
name
provide
a
!lescriptiQn Q,fthe re$ponsibi!ities.
of
that
person
with
regard
to the.
professional
services
being
provided
to.
each
designated pension plan.
lF1(7
,l
.4(j.
.(r
U , \ · · ().A1
JrM...=f'('"-
ow.
rw±
.
R
rt
-R
J.
"'
>""'8-.o! / .
:t.•
4
b · ·
2. Please
list
the
name
and.
title of
anyA!filiatedEtltity
and
their Executive-level
.611tployee{s)
that
require
dis9lasure;
t fter
.eac4
name,
incl'!\le
a brief
description oftheir duties, (See;
Definitions)
3. Ate
any ofthe
Individuals
named
in Item1or Itelll2
above,
a
currentorfotmer
official
or
employee
ofthe
Reqnesti
g·MuniCipality?
_.
IF
''YES'',
Provide
the
name.and
ofthe.person employed,
thei(positi<Jn
with
!he
municipality,
a!ld
dates.of employment.
4. Ate
any
oJthe
.iniJividuals
named
in
Item
1
or ltem
2.
above a
cutrent
(>r
fQrmer
registered
Federal
or
State lobbyist?
_.
IF "YES'\
provide
the
name ofthe individual,
specify
whether
they
are
a
state
0rfederallobbyist, and
the
<late
of
their
most
recent
registratiqn./renewal.
NOTICE:
All inf,mnation
provided
for
items
h
4
above
must
be
updated
as
changes
occu
,
S. Since
December
17'h
2009,
has
the'
Contractor
or an
4ffili(lted
Entity paid
compensation
to
or
employed
any
third
partyintermediary;
agent,
or.
lobbyist
that
is to
directly
or
indirectly
communicate With
an
official
or elllPloyee
oftheMmdcipal
Pension,System
ofthe Requesting
Municipality
(OR),
any
municipal
official
or employee
of
the
Requesting
Municipality in c,onnection,
With
any
lrll)1saction
or
investi11ent involving the
Contra
tor
arid
the
MuniCipal PensionSystem,ofthe
Requesting
MJ!ni¢ipality?
This
question,
does
not
apply to
an
officer
or elllPloyee
of
the
Contractor
who is acting within
the
scope
of
,the
firm's
stanqard
professional
duties
on
behalf
of
the
:ffrm, including
the !fctl)al Pn>vision
of
legal,
accounting,
engineering,
,real
estate,
,or
other pn>fessional
advice,
services,
or
assistance
pursuant
to
the
professional services
contactwith
mu11icipality's
pension
system.
-+ IF
"YES", iilentify:
(1)
whom
(the thirilparty
intetmecliary,
agent,.ot
lobb:jiist)waspaidthe
compensation
or .employed
by
the
Cotltractor or
Affiliated Entity,
(2)
their specific.
duties
. to
directly
or
indirectly
communicate
With
an official or
employee
of
the
Mttnicipal
Pension
Sy$tem
of the
Requesting
M)lnicipalitY
(OR),
any
municipal
official
or employee
of
the
Requesting
Municipality,
(3)
the official
they
communicated
with,
and
(4)
the
dates
ofthis.service.
6.
Since
December
171
20Q!!,lia.s
the
Cimtractor;orany
agent,
officer;
director
or
employee
oftlie
Contriictf)r
solicited
a
contribution
to any
municipal
officer
or
candidate
fomunicipal
office in
the
ReqJJesting Mlllticipality,
or
to
the
political party
or
political
action.
committee
ofthat6fficial
or
cMdidate?
-+
IF
••YES",
identifY
the agent,. officer,
director
or
employee who.
made the
solicitation
and
the
municipal
officials;
candidates, politiqal
party or
political
c.ommittee
who
were
solicited
(to
whom
the solicitation
was
made).
7. Since
.De
e1111icr
17"', 2009:Has
the
CtJntractor
or a11
Affiliated
E11tity
made any
contrib.utions
to
a municipal
official
or
any
candidate
for municipal
office.in
the
Requesting
MJJnicipallty?
-+
IF
"YES",
provide
.the
name and
address
of
the
person(s) makipg
the
contribution,
the contributor's
relationshiP
to the
Contractor,
The
nam¢
and office or
position
of
the
person receiving
the
contribution,
the
date
of the
contribution,
and
the
amount
of
the
contribution.
8.
Does
the
Co!itra tor
or an
Affiliated
Entity
have
andirect financial,
.¢onimercial
dr
business
relationship.
With
any official
identified
on the
List
ofMunicipa1Officials,
of the
Req11estfug
Municipality?
-+ IF
"YES", identify the.
individual
with whom the
relationship
exists
and
giye
a
d¢tailed
qescription
pf that
relationship.
·
**NOTE:
A
written
letter
is
required
from the
Req1Jesting
Municipality
acknowledging
the relationship and
consenting
to
its.
existence.
The
letter
must
he
attached
to
this
disclosure. Contact
the
Requesting
Mnnicipality to obtain
this
letter
and
attachittothis
disclosure
before
submission.
!i. Has the
Contractor
onn
Affiliated
Entity
given
any gifts
having
more
than a
nominal
va:lue
to
any
official, employee
or. fiduciary
-
specifically,
those
on
the
List of
Municipal
Olficinls of
the
Requesting Municipality?
•
IF
"YES",
Provide
the name
ofthe person conferring
the
gift,
the
person
receiving
the
gift,
the office or
position.of
the
person
receiving
the
gift,
specify
what the
gift
was,
and
the.date
conferred,
1.0.
Disclosure
ofcontributioos
to any
political
entityin theCommonwealth
of
Pennsylvania Applicability:
A
"yes"
response
is required
and
!411
disclosureis
required
ONLY
WHEN
ALL
of the following
applies:
a)
TI1e
contribution
was
made
within
the
last
5years (specificl\)ly
sioce:December
1&"'
2004)
b)
The
contribution
was
made
by
an
officer,
director, executive,level
employee
or
owner
of
at
least
5%
of the
Contr(!ctor
or
Affilipted
Entity•
.c)
The
aiilount
of
the
contribution
was
at
least $500
an<l
inthe form of:
l.
A single
contribution
by a
person
in
(b.)
above,
OR
2.
'rile
aggregate()£'
all conttibutionsall
persons
in(b.)
.above;
<!)
The contribution
was
for
l.
Any
candidate
forany public office
or
any person
who
holds
an
office
in
the
Commonwealth
ofPennsy)vani
;
2.
The
politicaLcommittee
of.a
candidate
for
public
office
or
any person.
that
holds
an office
in the Commonwealth
of
Peonsylvania.
•
IF
"YES", provide the
name
and
address.ofthe
person{s)
making
tile.
coriti'lbution,
the
c mtributor's relationship
to
the
Contractor,Thename
and
office
or
position
ofthe person receiving.the
contribution
(or
the political
entity
I
party
receiving
tlw
contribution),
the date qft)le
contribution,
and
the
amount
pfthe contribution.
ll.
With
respect to
your
provi.sion of professional
services
to
the
Municipal.Pension
System
of
the
Requesting
Municipallty;
Are you
aware
of
any
apparent,
potential
or
actual
conflicts
of
interest.with
respect
to any
officer,
director
.or
employee
of the
Contl'aCt(lr
Jlnd
officials
or
employees
ofthe ll,
questll)g
M:tJnlCipality?
NOTE:
If,.Ill
the
ftltlire, you
become.
aware
<if
any
apparent, potential,
or
acfual
conflict
ofinterest,
you
ate e){pectedto
update
this
:DisClosure
Form
immedi!ltely
in
wrilingby:
·
•
Providing
a
brief
synopsis
of the
conflict
of.interest{and);
• .An
explanation
of the
steps.taken
to
address this
apparent,potential,
or
actual
conflict
of
interest.
•
IF
''YES''•
PtQvide
a detailed
eJ<planation
ofthe circumstances
whichprovrde you
with
a
basis
to conoJude.that
an
apparent,
potential, or
actua!.conflict
ofinterest.may
exist.
12, '['o
the extent
tht you believe
that Chapter 7-A of
Act44 of
2009
requires youto disclose anyadditional inform!ltion
beyond
what has
been
J'(lqueste<i
above, please
provide
that i11f01mation
below or
o.n a
separate piece·ofpaper.
Please provide
the name(s) and
position(s) of
the
person(s)
participating in the
completion oft]lis
l)isclosure. One of
the individuals
identified by
the
Contractor
in
Item #1
above must participate
in
completing this
Disclosure and
must sign
the belOw
verificatio!J.!lttesting
to the
participation of those:individuals
named
below,
_______________________________________________________________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________