Jasper Coles Disclosure — File 26-0829

Name of municipal employee: Title/ Position Fill in this box if it applies to you. Agency/ Department Agency Address Office phone: Office e-mail: Starting date as a municipal employee. BOX # 1 Select either STATEMENT #1 or STATEMENT #2. Write an X beside your financial interest. BOX#2 Select either STATEMENT #1 or STATEMENT #2. DISCLOSURE BY MUNICIPAL EMPLOYEE OF FINANCIAL INTEREST IN A MUNICIPAL CONTRACT AS REQUIRED BY G. L. c. 268A, § 20(b) MUNICIPAL EMPLOYEE INFORMATION If you are a municipal employee because a municipal agency has contracted with your company or organization, please provide the name and address of the company or organization. /(/1 //t1A jpne N.~ lk- sl ·£cm,~ fl-1 /I 02 i3/ f Elected or J ELECTED MUNICIPAL EMPLOYEE I am an elected municipal employee. Non-elected STATEMENT #1: I had one of the following financial interests in a contract made by a municipal agency before I was elected to my municipal employee position. I will continue to have this financial interest in a municipal contract. OR _ STATEMENT #2: I will have a new financial interest in a contract made by a municipal agency. N)hfinancial interest in a municipal contract is: - ~_ I have a non-elected, compensated municipal employee position. __ A municipal agency has a contract with me. __ I have a financial benefit or obligation because of a contract that a municipal agency has with another person or an entity, such as a company or organization. __ I work for a company or organization that 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 city or town has contracted for my services in particular. NON-ELECTED, COMPENSATED MUNICIPAL EMPLOYEE I am a non-elected municipal employee. iiTATEMENT # 1: I had one of the following financial interests in a contract made by a municipal agency before I took a position as a non-elected municipal employee. I will continue to have this financial interest in a municipal contract.

Write an X beside your financial interest. Name and address of municipal agency that made the contract Please put in an X to confirm these facts. FILL IN THIS BOX OR THE BOX BELOW FILL IN THIS BOX OR THE BOX ABOVE My financial interest in a municipal contract is: __ A municipal agency has a contract With me, but not an employment contract. __ I have a financial benefit or obligation because of a contract that a municipal agency has with an'other person or an entity, such as a company or organization. -- OR -- •4; • J ST~TEMENT # 2: J w;II have a n~w financial interest in a contract made by a municipal agency. • • .._ - ·• • • • My financial interest in a municipal contract is: _..:!._ I have a non-elected, compensated municipal employee position . __ A municipal agency has a contract with me. I have a financial benefit or obligation because of a contract that a municipal agency has with ~-another person or an entity, such as a company or organization. __ I work for 21 company or-organization that 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 city or town has contracted for my services in particular. FINANCIAL INTEREST IN A MUNICIPAL CONTRACT l G 7 \(d lt c--✓ 5t "My Municipal Agency" is the municipal agency that I serve as a municipal employee. The "contracting agency" is the municipal agency thatmade the contract. J My Municipal Agency is not the contracting agency. J_ My Municipal Agency does not regulate the activities of the contracting agency. / In my work for my Municipal Agency, I do not participate in or have official responsibility for any of the activities of the contracting agency. { The contract was made after public notice or through competitive bidding. ANSWER THE QUESTION IN THIS BOX IF THE CONTRACT IS BETWEEN THE CITY OR TOWN AND YOU. - Please explain what the contract is for. ANSWER THE QUESTIONS IN THIS BOX IF THE CONTRACT IS BETWEEN THE CITY OR TOWN AND ANOTHER PERSON OR ENTITY. - Please identify the person or entity that has the contract with the municipal agency. - What is your relationship to the person or entity? - What is the contract for?

) What is your - Please explain the financial interest and include the dollar amount if you know it. financial interest ~-L S / ~ vu/ ffd!/w/( ~·~ In the municipal ~5 f /Vt r ~ contract? fC9, Sfr(, // y' Date when you ' acquired a financial ) (t (L cJ 2-6 interest What is the financial - Please explain the financial interest and include the dollar amount if you know it. interest of your immediate family? 1V/A Date when your rvA immediate family acquired ~ financial interest FOR A CONTRACT FOR PERSONAL SERVICES - Answer the questions in this box ONLY if you will have a contract for personal Write an X services with a municipal agency (i.e., you will do work directly for the contracting to confirm each agency). statement. I will have a contract with a municipal agency to provide personal services. 1_ The services Will be provided outside my normal working hours as a municipal employee. j__ The services are not required as part of my regular duties as a municipal employee. _j__ For these services, I will be compensated for not more than 500 hours during a calendar year. Employee signature: .-= A' ~-....::;:::;,----- Date: C: /7 / 1-- 0 1-C Attach additional pages if necessary. NOT A PERSONAL SERVICES CONTRA CT -- File disclosure with the city or town clerk. SEE CERTIFICATION AND APPROVAL REQUIRED FOR PERSONAL SERVICES CONTRACTS, BELOW.

FOR CONTRACTS FOR PERSONAL SERVICES ONLY: If you.are disclosing a financial interest-in; a. c:ontraetr.for personal services with a municipal agency, you must file the Certification below signed by the head of the contracting agency, and you must get approval of the exemption from the city council, board of aldermen, _board of selectmen or town council. Name: Title/ Position Municipal Agency: - Agency Address: Office Phone: Signature: Date: Name: Title/ Position Agency Address: Office Phone: Signature: Date: Form revised February, 2012 CERTIFICATION BY HEAD OF CONTRACTING AGENCY INFORMATION ABOUT HEAD OF CONTRACTING AGENCY () herY? e v•c.; K4 e)Jtt.m,iJt le:J/11 .. ft.'!) ✓. ~ .~erc4·~~-u'l'1-'1 D I I e-vf.oQ jl)rvl /!)/ V //k f}av i65 . ,P ?,,e,,eA' e~l,~ lbt //tJ // pviJ .s. I . /2-t? ¢) f,'],;1 --Z,0£ ;½;V2 e,y V / lk /tlct D'Zt1/~f ~I/--- &:J,:t -~ ~~ {)0 11AI cJ '1'96 CERTIFICATION I have received a disclosure under G.L. c. 268A, § 20(b) from a municipal employee who seeks to provide personal services to my municipal agency, identified above. I certify that no employee of my agency is available to perform the .services described above as part of bi5.~L. re~~ar duties • . #//_~~ \ lj·- !3 -~p APPROVAL BY CITY COUNCIL, BOARD OF ALDERMEN, BOARD OF SELECTMEN OR TOWN COUNCIL INFORMATION ABOUT APPROVING BODY APPROVAL I have received a disclosure under G.L. c. 268A, § 20(b} from a municipal employee who seeks to provide personal services to a municipal agency, identified above. The exemption under§ 20(b) is approved. On behalf of the Council or Board, I sign this approval. Attach additional pages if necessary. File disclosure, Certification and Approval with the city or town clerk.