ACT 44 DISCLOSURE FORM FOR ENTITIES PROVIDING

ACT 44 DISCLOSURE FORM FOR ENTITIES PROVIDING
PROFESSIONAL SERVICES TO THE
BOROUGH OF SOMERSET'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 the Borough of Somerset (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 November 30, 2015. 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 November 15, 2015.
RETURN COMPLETED
DISCLOSURE TO:
Borough of Somerset
Attn: Michele A. Enos, Manager
POBox71
Somerset, Pa. 15501
1011
Uill
E-mail Address - [email protected]
REQUIRED UPDATES:
Where noted, information in this form must be updated in writing as changes occur.
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Ao};~
DEFINITIONS FOR DISCLOSURE
CONTRACTOR
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.
SUBCONTRACTOR OR ADVISOR
Anyone who is paid a fee or receives compensation from a municipal
pension system - directly or indirectly from or through a contractor.
AFFILIATED ENTITY
Any of the following:
1. 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) of the 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
As defined in section 1621 of the act of June 3'd, 1937 (P.L. 1333, No.
320), known as the Pennsylvania Election Code
POLITICAL COMMITIEE
As defined in section 1621of the act of June 3'd, 1937 (P.L. 1333, No.
320), known as the Pennsylvania Election Code
EXECUTIVE LEVEL EMPLOYEE
Any employee or person or the person's affiliated entity who:
1. 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
municipal pension system.
MUNICIPAL PENSION SYSTEM
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
MUNICIPAL PENSION SYSTEM
OFFICIALS AND EMPLOYEES;
MUNICIPAL OFFICIALS AND
EMPLOYEES
Specifically, those listed in TABLE 2 titled: "List of Pension System
Municipal Officials and Employees" on the next page. Where
applicable, includes any employee of the Requesting Municipality.
PROFESSIONAL SERVICES
CONTRACT
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.
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and
List of Municipal Officials 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 refened to as the "List of Municipal Officials."
Elected Officials
Ruby W. Miller - Borough Council President
Fredric Rosemeyer - Borough Council Vice-President
Judy Pyle - President Pro-Tern - Council Member
Pamela Ream - Council Member
Gary Thomas - Council Member
Sue Opp - Council Member
Steve Shaulis - Council Member
Scott Walker - Mayor
Appointed Officials I Employees
Michele A. Enos - Borough Manager CAO, Collective Bargaining Plan I CAO, Police Plan I CAO, NonCollective Bargaining Plan
Brett B. Peters - Director of Finance
John J. Dirienzo, Jr., Esq. - Borough Solicitor
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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 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":
~nfr~t~ -g-3tf3J
$3'133
~
D
Non- Uniform Plan
D
Police Plan
FirePlan
**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.
2. Please list the name and title of any Affiliated E11tity and their Executive-level Employee(s) that require
disclosure; after each name, include a brief description of their duties. (See: Definitions)
!V/11
3. Are any of the individuals nar'J~)li Item 1 or Item 2 above, a current or former official or employee of the
Requesting Municipality? /Y {/
... IF "YES", provide the name and of the person employed, their position with the municipality, and dates of
employment.
4. Are any of !hr individuals named in Item 1 or Item 2 above a current or former registered Federal or State
lobbyist? /LI
... 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.
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NOTICE: All information provided for items 1- 4 above must be updated as changes occur.
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Since December I 7'h 2009, has the Contractor or an Affiliated Entity paid compensation to or employed
any third party intermediary, agent, or lobbyist that is to directly 01· 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
Co11tractor and the Municipal Pension System of the Requesting Municipality?
This question docs not a poly 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 intennediaty, 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.
5.
NQ
6. Since December 171h 2009, has the Contrac/01; or any agent, officer, director or employee of the Coutractor
solicited a contribution to any municipal officer or candidate for municipal office in the Req}\sting
Municipality, or to the political party or political action committee of that official or candidate?
-+ IF "YES", identify the agent, officer, director or employee who made the solicitation and the munfoipal
officials, candidates, political party or political committee who were solicited (to whom the solicitation was
made).
NV
7. Since December 17'', 2009: Has the Contractor or an Affiliated Entity made any c~Ol}ll;iQ.utions to a
municipal official or any candidate for municipal office in the Requesting Municipality? /V l/
-+ 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 Co11tractor or an Affiliated Eutity have any direct financial, commercial or business r5JaJiP1lship
with any official identified on the Lisi ofM1111icipal Officials, of the Requesting Municipality? /I./ {/
-+ IF "YES", identify the individual with whom the relationship exists and give a detailed description of that
relationship.
**NOTE: A written 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.
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9. Has the Contractor or an Affiliated Entity given any gifts having more than a nominal value to any official,
employee or fiduci~· - specifically, those on the List of Municipal Officials of the Requesting
Municipality?
-+ IF "YES", Pro& ie 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 conferred.
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:
a) The contribution was made within the last 5 years (specifically since: December IS'h 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 of the 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. AJ()
-+
IF "YES", provide the name and address of the perlon(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 of the contribution, and the amount of the
contribution.
11. With respect to your provision of professional services to the Municipal Pension System of the Requesting
Municipality:
Arc you aware of any apparent, potential or actual conflicts of interest with respect to any officer, director or
employee of the Contractor and officials or employees of the Requesting Municipality?
NOTE: If, in the future, you become aware of any apparent, potential, or actual 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.
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12. To the extent that you believe that Chapter 7-A of Act 44 of2009 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.
Please provide the name(s) and position(s) of the person(s) pmticipating 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:l.avr1e..-
.
LJ'6tr7CL
Name:
Position:
Position:
Name:
Name:
Position:
Position:
~&/1/
SIGNATURE
Tfff E vnf lllanafJ~r
1~!¥s:
DATE
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VERIFICATION
r,
Lflur1e
[l!iinrL
(Name)
,
hereby state that I am
1JMe/a f(!JMilo) fuvp
and
I
am
f/u-Dv ntr1an4!fr
for
(Position)
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 the Borough of Somerset 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 ui1sworn falsification to authorities.
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