CITY OF SOMERVILLE
E
THICS COMMISSION FOR CALENDAR YEAR
STATEMENT OF FINANCIAL INTERESTS ____________
This form is prepared pursuant to Somerville Code of Ordinances, Chapter 15.
Please note: Any person who is required to file a statement of financial interest pursuant to
Massachusetts General Laws, Chapter 268B shall be deemed to have complied with the requirements of
Somerville Ordinance 1997-5 if the person files a certified copy of the State report with the Somerville
Commission either by the dates required pursuant to said Chapter 268B or those required pursuant to
Somerville Ordinance 1997-5, whichever is later.
Filing period January 1, ______ - December 31, _________
Name: ______________________
Address: ______________________
Election Commission
will place its stamp here
______________________ as official receipt of filing
Telephone: Home:_________________ Cell: ___________________
Work: ________________
Fax: __________________ Email: __________________
Candidate for, or, Office/Position Held: ________________________________
Name of Spouse and/or any dependent children residing in your household:
Name of Spouse: ___________________
Name(s) of dependent children residing in household: _______________________________________
___________________________________________________________________________________
Suggestion: Please read through the entire form before inserting information. Do not hesitate to
contact the City Solicitor’s Office for assistance at (617) 625-6600, ext. 4400.
DEFINITIONS
Whenever used in this chapter, the following terms shall
have the following meanings, unless the context requires
otherwise:
Adjudicatory proceeding means a formal, confidential
investigation conducted by the commission, in which all
parties in interest have an opportunity to be heard;
Affinity means related by marriage;
Amount means a category of value, rather than an exact
dollar figure, as set forth in M.G.L.A. c.268B, § 1(a);
provided, however, that the commission may adopt
different categories by a roll call vote of the commission;
and provided, further, that the mayor, board of aldermen
and school committee shall be notified, in writing, of any
such action of the commission along with reasons for
such action.
Whenever this form asks for an “amount”, the reply may be
a category of value, as follows:
Greater than $1,000.00 but not more than
$5,000.00;
Greater than $5,000.00 but not more than
$10,000.00;
Greater than $10,000.00 but not more than
$20,000.00;
Greater than $20,000.00 but not more than
$40,000.00;
Greater than $40,000.00 but not more than
$60,000.00;
Greater than $60,000.00 but not more than
$100,000.00; and
Greater than $100,000.00;
Application means a proposal or similar document
written to apply for any grant and/or trust fund program.
Business means any corporation, partnership, sole
proprietorship, firm, franchise, association, organization,
holding company, joint stock company, receivership,
business trust, or other legal entity organized for profit or
charitable purposes; provided, however, any relationship
which would appear to be a business association to an
objective, reasonable person, regardless of the formal
relationship, shall be considered a "business" for the
purposes of this chapter; and provided, further, that this
term shall include any fee splitting arrangement with a
person subject to the requirements of this chapter;
Business Associate means any relationship which
would appear to be a business association to an
objective, reasonable person, regardless of the formal
relationship, including any fee splitting arrangement.
Candidate for public office means any individual who
seeks nomination or election to the office of mayor,
alderman or school committee;
City means the City of Somerville;
City agency or department shall have the same
meaning as municipal body.
City charter means the Charter of the City of Somerville;
City official or employee means any person performing
services for the city or holding an office, position,
employment or membership in a city agency, whether by
election, appointment, contract of hire or engagement,
whether serving with or without compensation, on a full,
regular, part-time, intermittent, or consultant basis.
City solicitor means the city solicitor for the city;
Commission means the ethics commission created
pursuant to this chapter;
Consanguinity means related by blood;
Designated municipal official means any of those city
employees who hold the positions specified on a list
submitted by the mayor to the commission by January 31
of each year; provided, however, such list shall include
only those employees whose total compensation from
the city for the reporting period is amongst the top 150
and who hold major policy making positions and in
addition, any city employee(s) in the title of "project
manager," who shall have the responsibility for managing
projects of building construction or any other public
works where the total expenditure for such project is
estimated or expected to exceed $1,000,000.00;
provided, further, that the commission may request the
mayor to add a specific position to the list and, if the
mayor declines, may request the board of aldermen to
add such position by a two-thirds roll call vote;
Direct and substantial interest in a particular matter
shall be applied as interpreted under M.G.L.A. c. 268A,
commonly known as the Conflict of Interest and Code of
Conduct Law;
Elected official means the mayor, aldermen and school
committee of the city;
Election commission means the election commission of
the city;
Grant and/or grant funds means city funds disbursed
as part of a federal or state pass-through or direct grant
program by a city agency or department.
Grantee means a non-city entity that receives grant
and/or trust funds from a city agency or department.
Equity means any stock or similar ownership interest in
a business;
Gift means a payment, entertainment, subscription,
advance, services or anything of value, unless
consideration of equal or greater value is received;
provided, however, "gift" shall not include a political
contribution reported as required by law, a commercially
reasonable loan made in the ordinary course of
business, or anything of value received by inheritance;
Honoraria means payment for services which is not
customarily subject to a set price such as making a speech;
Immediate family includes a spouse and any dependent
children residing in the reporting person's household;
Income means income from whatever source derived,
whether in the form of a fee, salary, allowance,
forbearance, forgiveness, interest, dividend, royalty, rent,
capital gain, or any other form of recompense or any
combination thereof; provided, however, that interest
from savings accounts or from governmental obligations
other than those of the commonwealth or any political
subdivision thereof or any public agency or authority
created by the general court, alimony and support
payments, proceeds from a life insurance policy,
retirement or disability benefits, and social security
payments shall not be considered income for the
purposes of this chapter;
Municipal body means any agency, authority, board,
bureau, commission, committee, council, department,
division, school department, or other legal entity within
the government of the city;
Municipal election means any preliminary, final or
special election where the name of the relevant party
shall appear on the ballot;
Person means a business, individual, corporation,
union, association, firm, partnership, committee, or other
organization or group of persons;
Preliminary inquiry means an informal, confidential
investigation conducted by the commission, which may
or may not accept written or verbal testimony;
Relative means any person related within the third
degree of consanguinity or affinity; and
Reporting person means any person required to file a
statement pursuant to this chapter.
Subgrantee means a non-city entity that receives city
grant and/or trust funds from a grantee or from another
subgrantee.
Trust and trust funds means city funds disbursed from
a municipally established trust fund.
DISCLOSURES
Unless otherwise specified, all of the following
information must be provided for the reporting person
and for that person’s immediate family. Attach additional
pages if more space is needed.
STATEMENT OF FINANCIAL INTERESTS
DISCLOSURE 1A.
1A. Business Associations. State the name and address of each business (defined as any legal
entity organized for profit or charitable purposes) in which you or a member of your immediate family is
associated; provided, however, that the reporting person need not report an ownership or equity interest
in a business in which the reporting person or the reporting person’s immediate family owns or otherwise
controls five percent or less of the business. Include the nature of your or your family’s association with
each business and the amount of income received if greater than one thousand dollars ($1,000.00). SCO
§ 15-8(A).
Not applicable
INCOME RECEIVED BY YOU:
BUSINESS NAME
AND ADDRESS
NATURE OF
ASSOCIATION
SHARE
OF
EQUITY
AMOUNT OF
ANNUAL
INCOME
INCOME RECEIVED BY YOUR IMMEDIATE FAMILY MEMBER:
BUSINESS NAME
AND ADDRESS
NAME AND
RELATIONSHIP
NATURE OF
ASSOCIATION
SHARE
OF
EQUITY
AMOUNT OF
ANNUAL
INCOME
STATEMENT OF FINANCIAL INTERESTS
DISCLOSURE 1B.
1B. Employment. State the name and address of each business (defined as any legal entity
organized for profit or charitable purposes) from which you or your immediate family received a salary,
including any salary from the City of Somerville. Include the nature of your or your family’s association
with each business and the amount of income received if greater than one thousand dollars ($1,000.00).
SCO § 15-8(A).
Not applicable
EMPLOYMENT BY YOU:
EMPLOYER
NAME & ADDRESS
POSITION
AMOUNT OF
ANNUAL INCOME
EMPLOYMENT BY YOUR IMMEDIATE FAMILY MEMBERS:
EMPLOYER
NAME & ADDRESS
NAME &
RELATIONSHIP
POSITION
AMOUNT OF
ANNUAL INCOME
STATEMENT OF FINANCIAL INTERESTS
DISCLOSURE 2.
2. Securities and Investments. List all securities and investments beneficially owned by you or a
member of your immediate family with a fair market value of greater than one thousand dollars as of the
last date held during the reporting period, and the amount of income from any such security.
This information need not be provided unless your beneficial interest represents more than five
percent of the total interest. You need not report securities held as part of a mutual fund, deferred
compensation fund, individual retirement fund, certificate of deposit, or some other generalized fund
which is open to public investment. SCO § 15-8(B).
Not applicable
SECURITY/INVESTMENT
OWNER OF SECURITY
AMOUNT OF
ANNUAL INCOME
You
Your immediate family
Name & Relationship:
You
Your immediate family
Name & Relationship:
You
Your immediate family
Name & Relationship:
STATEMENT OF FINANCIAL INTERESTS
DISCLOSURE 3.
3. Certain Credit Obligations. State the name and address of each creditor to whom more than
one thousand ($1,000.00) was owed at any time during the reporting year by you, the original amount
owing, the amount outstanding, the general nature of the security pledged for each obligation, and the
terms of repayment (the annual interest rate and either the year final repayment is due or in the case of
ongoing credit, the frequency of required payments, e.g., monthly).
The following need not be reported:
a) the original amount and the amount outstanding for a mortgage of your primary residence;
b) the obligations on retail installment transactions, educational loans, medical and dental
expenses, debt incurred in the ordinary course of an active ongoing business,
c) alimony or support obligations; and
d) any obligation in which the creditor is related within the third degree of consanguinity or
affinity.
SCO § 15-8(C)
Not applicable
CREDITOR
ADDRESS
ORIGINAL
AMOUNT
AMOUNT
OWING
TERMS
RATE/TIME
SECURITY
STATEMENT OF FINANCIAL INTERESTS
DISCLOSURE 4.
4. Reimbursements. State the name and address of the source, and cash value of any
reimbursements for any person who reimbursed you or any member of your immediate family for
expenses aggregating more than one hundred dollars ($100.00) during the reporting period.
This information need not be reported unless the reimburser has a direct and substantial interest in
a matter before a municipal body. This section shall apply only to those situations that are not in violation
of Chapter 268A of the Massachusetts General Laws. SCO § 15-8(D).
Not applicable
REIMBURSER’S NAME & ADDRESS RECIPIENT AMOUNT
You
Your immediate family
Name & Relationship:
You
Your immediate family
Name & Relationship:
You
Your immediate family
Name & Relationship:
You
Your immediate family
Name & Relationship:
STATEMENT OF FINANCIAL INTERESTS
DISCLOSURE 5.
5. Donations and Gifts. State the name and address of any donor, and fair market value, if
determinable, of any gifts to you or your immediate family aggregating more than one hundred dollars
($100.00) in the calendar year, if the source of any such gift is a person having a direct interest in any
matter before a municipal body.
No such gifts need be reported if the person making the gift is a relative of yours or of any member
of your immediate family within the third degree of consanguinity or affinity; and provided further, that this
subsection shall apply only to those situations that are not in violation of Chapter 268A of the
Massachusetts General Laws. SCO § 15-8(E).
Not applicable
DONOR’S NAME & ADDRESS RECIPIENT VALUE
You
Your immediate family
Name & Relationship:
You
Your immediate family
Name & Relationship:
You
Your immediate family
Name & Relationship:
STATEMENT OF FINANCIAL INTERESTS
DISCLOSURE 6.
6. Assessed Value of Real Property. Describe (using the description on your most recent
property tax bill), including address and value, all real property (real estate) in which a beneficial interest
was held by you which has an assessed value greater than one thousand dollars ($1,000.00) as of the
last date held during the reporting period. If the real property was transferred during the reporting period,
state the name and address of the person furnishing consideration to, or receiving it from, you. This
information need not be reported if your beneficial interest represents five percent or less of the total
interest in the property. SCO § 15-8(F).
Not applicable
PROPERTY ADDRESS
ASSESSED VALUE FROM
MOST RECENT TAX BILL
TRANSFEROR/TRANSFEREE
(If during reporting period)
STATEMENT OF FINANCIAL INTERESTS
DISCLOSURE 7.
7. Honoraria. State the name and address of the source and fair market value of any honoraria
received by you or your immediate family aggregating more than one hundred dollars ($100.00) if the
source is a person having a direct and substantial interest in a particular matter before a municipal body.
This section shall apply only to those situations that are not in violation of Chapter 268A of the
Massachusetts General Laws. SCO § 15-8(G).
Not applicable
NAME AND ADDRESS OF
SOURCE OF HONORARIA AND
DESCRIPTION OF SUBSTANTIAL
INTEREST
RECIPIENT
FAIR MARKET VALUE
You
Your immediate family
Name & Relationship:
You
Your immediate family
Name & Relationship:
You
Your immediate family
Name & Relationship:
You
Your immediate family
Name & Relationship:
STATEMENT OF FINANCIAL INTERESTS
DISCLOSURE 8.
8. Forgiven Debts. State the name and address of any creditor who voluntarily forgave a debt of
yours during the reporting period of over one thousand dollars ($1,000.00) and the amount forgiven.
This information need not be provided if the creditor is a relative of yours or of any member of your
immediate family within the third degree of consanguinity or affinity. SCO § 15-8(H).
Not applicable
CREDITOR
ADDRESS AMOUNT FORGIVEN
STATEMENT OF FINANCIAL INTERESTS
DISCLOSURE 9.
9. Leaves of Absence. State the name and address of any business from which you or any member
of your immediate family took a leave of absence during the reporting period . SCO § 15-8(I)
Not applicable
BUSINESS NAME AND ADDRESS PERSON TAKING LEAVE
You
Your immediate family
Name & Relationship:
You
Your immediate family
Name & Relationship:
You
Your immediate family
Name & Relationship:
STATEMENT OF FINANCIAL INTERESTS
DISCLOSURE 10.
10. Transfer of Equity. Identify the equity (defined as any stock or similar ownership interest) in any
business with which you or any member of your immediate family is associated that has been transferred
to another person during the reporting year. This information need not be provided if the beneficial
interest represents five percent or less of the total interest held. SCO § 15-8(J).
Not applicable
EQUITY
OWNER OF EQUITY
RECIPIENT
You
Your immediate family
Name & Relationship:
You
Your immediate family
Name & Relationship:
You
Your immediate family
Name & Relationship:
STATEMENT OF FINANCIAL INTERESTS
DISCLOSURE 11
11. Commercial or Business Transactions. State the nature, amount, and date of any commercial
or business transaction including, but not limited to, loans, worth two hundred and fifty dollars ($250.00)
or more between any municipal official (elected or appointed) and you or a member of your immediate
family. SCO § 15-8(K).
Not applicable
NATURE OF
TRANSACTION
AMOUNT
ASSOCIATION
NAME OF
MUNICIPAL
OFFICIAL
DATE
You
Your immediate family
Name & Relationship:
You
Your immediate family
Name & Relationship:
You
Your immediate family
Name & Relationship:
STATEMENT OF FINANCIAL INTERESTS
DISCLOSURE 12.
12. Your or Your Family’s Clients/Customers Interests in a Municipal Body. State the name,
address and nature of association of any clients and customers of yours or of your immediate family who
have a direct and substantial interest in a particular matter before a municipal body.
This information need not be reported if the amount paid, owed or accrued by the client or
customer during the reporting period does not exceed two hundred fifty dollars ($250.00); and provided,
further, this subsection shall apply only to those situations that are not in violation of Chapter 268A of the
Massachusetts General Laws. SCO § 15-8(L).
Not applicable
CLIENT/CUSTOMER NAME
AND ADDRESS
ASSOCIATION
NATURE OF ASSOCIATION
and DESCRIPTION OF
SUBSTANTIAL INTEREST
You
Your immediate family
Name & Relationship:
You
Your immediate family
Name & Relationship:
You
Your immediate family
Name & Relationship:
STATEMENT OF FINANCIAL INTERESTS
DISCLOSURE 13.
13. Business Associates’ Clients/Customers Interests in a Municipal Body. State the name,
address and nature of association of any clients and customers of any business associate of yours or of
your immediate family who have a direct and substantial interest in a particular matter before a municipal
body.
This information need not be reported if the amount paid, owed or accrued by the client or
customer during the reporting period does not exceed two hundred fifty dollars ($250.00); and provided,
further, this subsection shall apply only to those situations that are not in violation of Chapter 268A of the
Massachusetts General Laws. SCO § 15-8(M).
Not applicable
BUSINESS
ASSOCIATE’S NAME
CLIENT/CUSTOMER’S
NAME & ADDRESS
NATURE OF ASSOCIATION
and DESCRIPTION OF
SUBSTANTIAL INTEREST
STATEMENT OF FINANCIAL INTERESTS
DISCLOSURE 14.
14. Employees of the City. State the name, address, job title, any change in title, job description or
pay, and year of original hire of any relative of yours or of your immediate family who received pay from
the city as an employee during the reporting period.
This information need not be reported if the relative is not within the third degree of consanguinity
or affinity; and provided further, that any relative who is retired and receiving no pay from the city other
than retirement pay for more than six months during the reporting period need not be reported. SCO§
15-8(N).
Not applicable
NAME, ADDRESS AND
RELATIONSHIP
JOB TITLE
SPECIFY ANY CHANGE IN
JOB TITLE,JOB DESCRIPTION OR PAY
DURING REPORTING PERIOD
DATE OF
HIRE
STATEMENT OF FINANCIAL INTERESTS
DISCLOSURE 15.
15. City Contracts. State the name, address, amount of payment received during the reporting
period, and year of original agreement of any relative of yours or of your immediate family who received
payment from the city as a contractor during the reporting period.
This information need not be reported if the relative is not within the third degree of consanguinity
or affinity. SCO § 15-8(O).
Not applicable
NAME, ADDRESS AND
RELATIONSHIP OF
CONTRACTOR
AMOUNT OF
PAYMENT
YEAR OF
ORIGINAL
AGREEMENT
TYPE OF
CONTRACT
STATEMENT OF FINANCIAL INTERESTS
DISCLOSURE 16.
16. Business Associates’ City Employment. State the name, address, job title, any change in title,
job description or pay, and year of original hire of any relative of any business associate of yours or of
your immediate family who received pay from the city as an employee during the reporting period.
This information need not be reported for any person who is retired and receiving no pay from the
city other than retirement pay for more than six months during the reporting period. SCO § 15-8(P).
Not applicable
NAME, ADDRESS AND
RELATIONSHIP
JOB TITLE
SPECIFY CHANGE IN JOB TITLE, JOB
DESCRIPTION OR PAY
DATE OF
HIRE
STATEMENT OF FINANCIAL INTERESTS
DISCLOSURE 17.
17. Business Associates’ City Contracts. State the name, address, amount of payments received
during the reporting period, and year of original agreement of any relative of any business associate of
yours or of your immediate family who received payment from the city as a contractor during the reporting
period. SCO § 15-8(Q).
Not applicable
NAME, ADDRESS AND
RELATIONSHIP TO
BUSINESS ASSOCIATE
AMOUNT OF
PAYMENT
YEAR OF
ORIGINAL
AGREEMENT
TYPE OF
CONTRACT
STATEMENT OF FINANCIAL INTERESTS
DISCLOSURE 18 &
SIGNATURE PAGE
18. Nothing in this Statement of Financial Interests shall be construed to require the disclosure of
information which is privileged by law; provided, however, that you include notice that there is information
being withheld pursuant to this paragraph and the category such information would have fallen into if it
had been reported. SCO § 15-8, last paragraph.
Not applicable
NOTICE OF WITHHELD INFORMATION, INDICATING APPLICABLE QUESTION NUMBER:
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
____________________________________
I swear under the penalties of perjury that the information in this Statement of Financial Interests,
and on any attached pages, is true to the best of my knowledge. I understand that filing a deficient or
false Statement of Financial Interests may result in legal action being taken against me.
____________________________
Signature Date