Choitz JCRT special-munic-contract-new signed — File 24-1081

DISCLOSURE BY SPECIAL MUNICIPAL EMPLOYEE OF FINANCIAL INTEREST IN A MUNICIPAL CONTRACT AS REQUIRED BY G. L. c. 268A, § 20(d) SPECIAL MUNICIPAL EMPLOYEE INFORMATION Name of special municipal employee: Victoria K. Choitz Put an X beside one statement. I am a special municipal employee because: ___ I am a selectman in a town with a population of 10,000 or fewer people; _X__ I am not a mayor, alderman or city councilor, and _X__ I serve in a municipal position for which no compensation is provided, or ___ I earned compensation for fewer than 800 hours in the preceding 365-day period, or ___ By the classification of my position by my municipal agency or by the terms of a contract or my conditions of employment, I am permitted to have personal or private employment during normal business hours. ___ I work for a company or organization which has a contract with a municipal agency, and I am a “key employee” because the contract identifies me by name or it is otherwise clear that the municipal is contracting for my services in particular, and the contract states that I am a special municipal employee or indicates that I meet one of the three requirements listed above. Title/ Position Co-chair, Somerville Jobs Creation and Retention Trust Board Fill in this box if it applies to you. If you are a special municipal employee because a municipal agency has contracted with your company or organization, please provide the name and address of the company or organization. Municipal Agency/ Department: This is “my Municipal Agency.” Somerville Economic Development Division of the Office of Strategic Planning and Community Development (OSPCD) Agency Address: 93 Highland Ave. Somerville, MA 02143 Office phone: [phone removed] x2515 Office e-mail: economicdevelopment@somervillema.gov Check one: ____ Elected or _X___ Non-elected Starting date as a special municipal employee. January 2019 BOX # 1 ELECTED SPECIAL MUNICIPAL EMPLOYEE

Select either STATEMENT #1 or STATEMENT #2. Write an X by your financial interest. I am an elected special municipal employee. ___ STATEMENT #1: I had a financial interest in a contract made by a municipal agency before I was elected to a compensated special municipal employee position. I will continue to have this financial interest in a municipal contract. ___ STATEMENT #2: I will have a new financial interest in a contract made by a municipal agency. My financial interest in a contract made by a municipal agency is: ___ A compensated, non-elected position with a municipal agency. ___ A contract between a municipal agency and myself. ___ A financial benefit or obligation because of a contract that a municipal agency has with another person or with a company or organization. ___ Other work because a municipal agency has a contract with my company or organization and I am a “key employee” because the contract identifies me by name or it is otherwise clear that the municipal is contracting for my services in particular. BOX #2 Select either STATEMENT #1 or STATEMENT #2. Write an X by your financial interest. NON-ELECTED SPECIAL MUNICIPAL EMPLOYEE I am a non-elected special municipal employee (compensated or uncompensated). ___ STATEMENT #1: I had a financial interest in a contract made by a municipal agency, other than an employment contract, before I took a non-elected, compensated special municipal employee position. I will continue to have this financial interest in a municipal contract. My financial interest in a contract made by a municipal agency is: ___ A contract between a municipal agency and myself, but not an employment contract. ___ A financial benefit or obligation because of a contract that a municipal agency has with another person or with a company or organization. OR _X__ STATEMENT #2: I will have a new financial interest in a contract made by a municipal agency. My financial interest in a contract made by a municipal agency is: ___ A compensated, non-elected position with a municipal agency. ___ A contract between a municipal agency and myself. ___ A financial benefit or obligation because of a contract that a municipal agency has with another person or with a company or organization. _X__ Other work because a municipal agency has a contract with my company or organization and I am a “key employee” because the contract identifies me by name or it is otherwise clear that the municipal is contracting for my services in particular. FINANCIAL INTEREST IN A MUNICIPAL CONTRACT Name and address of municipal agency that made the contract This is the “contracting agency.” Somerville Economic Development Division Office of Strategic Planning and Community Development (OSPCD) 93 Highland Ave. Somerville, MA 02143 Write an X to confirm this statement. _X__ In my work as a special municipal employee for my Municipal Agency, I participate in or have official responsibility for activities of the contracting agency. ANSWER THE QUESTION IN THIS BOX

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APPROVAL OF EXEMPTION BY THE CITY COUNCIL, BOARD OF ALDERMEN, BOARD OF SELECTMEN, TOWN COUNCIL OR DISTRICT PRUDENTIAL COMMITTEE Name: Name of approving body: Write an X by one selection. ___ City Council ___ Board of Aldermen ___ Board of Selectmen ___ Town Council ___ District Prudential Committee Title/ Position Agency Address: Office phone: APPROVAL OF § 20(d) EXEMPTION We have received a disclosure under G.L. c. 268A, § 20(d) from a special municipal employee who seeks to have a financial interest in a contract made by a municipal agency of this city or town. We understand that the special municipal employee participates in, or has official responsibility for, activities of the municipal agency that made the contract. We approve this exemption under § 20(d) regarding the financial interest identified by the special municipal employee. Signature: On behalf of the Council, Board or Committee identified above, I sign this approval. Date: Attach additional pages if necessary. File your completed, signed, approved Disclosure with the city or town clerk. Form revised February, 2012