DISCLOSURE UNDER G.L. c. 268A, § 23(b)(3)

OF RECEIPT OF HONORARY DEGREE

AS REQUIRED BY 930 CMR 5.08(5)

PUBLIC EMPLOYEE POSITION
Name of public employee:
Title or Position:
Agency/Department:
Agency address:
Office Phone:
Office E-mail:
Write an X beside all that apply. / ___ I have accepted an honorary degree from a public or private educational institution given in whole or in part for my official actions or position as a state, county or municipal employee. The degree did not include a monetary award of substantial value (i.e., worth $50 or more).
____ I have accepted reasonable travel expenses related to the conferral ceremony. These expenses were given to me and guests accompanying me in accordance with the criteria and policies of the educational institution.
Put an X beside the relevant statement about a six-month period. / I am filing this disclosure because
____ A particular matter involving the giver previously came before me within the six months prior to my acceptance of the honorary degree; or
____ A particular matter involving the giver is coming before me during the six months after I accepted the honorary degree.
My purpose in filing the disclosure is to dispel the appearance that the educational institution that gave me the honorary degree can unduly enjoy my favor or improperly influence me in the performance of my official duties, or that I am likely to act or fail to act as a result of someone’s kinship, rank, position or undue influence.
RECEIPT OF HONORARY DEGREE AND/ OR RELATED TRAVEL EXPENSES
What educational institution gave you the honorary degree?
Date, time and location of degree ceremony
Name and address of person or organization that paid your expenses
TRAVEL EXPENSES RELATED TO THE DEGREE CEREMONY –
Please report these expenses in detail.
Provide information in as much detail as possible: / Itemization and explanation of amounts offered:
Transportation: / Air, train, bus, and taxi fare and rental car hire, etc.
Lodging: / Overnight accommodations.
Meals: / Breakfast, lunch, dinner, special events.
Admission: / Admission, tickets, etc.
Other (please list): / Refreshment, materials, entertainment, etc.
Total:
Date when you accepted the expenses
PARTICULAR MATTER REGARDING THE GIVER
Answer questions below if applicable / MATTER THAT CAME BEFORE YOUWITHIN SIX MONTHSBEFORE
YOU RECEIVE THE HONORARY DEGREE
Describe the matter regarding the giver that came before youfor decision or official action.
Date when
the matter
camebefore you
What responsibility did you have for taking action or making a decision?
Answer questions below if applicable / MATTER THAT WILL COME BEFORE YOUWITHIN SIX MONTHSAFTER
YOU RECEIVED THE HONORARY DEGREE
Describe the matter regarding the giver that is coming before youfor decision or official action.
Date when the matter is coming before you
What responsibility do you have for taking action or making a decision?
If you cannot confirm this statement,
you should
recuse yourself. / REGARDING YOUR FUTURE ACTION,
WRITE AN X TO CONFIRM THE STATEMENT BELOW.
___ Taking into account the facts that I have disclosed about receiving an honorary degree, I feel that I can perform my official duties objectively and fairly with regard to the matter I have described above.
Employee signature:
Date:

Attach additional pages if necessary.

Not elected to your public position – file with your appointing authority.

Elected state or county employees – file with the State Ethics Commission.

Members of the General Court – file with the House or Senate clerk or the State Ethics Commission.

Elected municipal employee – file with the City Clerk or Town Clerk.

Elected regional school committee member – file with the clerk or secretary of the committee.

Form revised February, 2012