2.3.12. Disclosure Statement.docx

COMMONWEALTH OF MASSACHUSETTS

MASSACHUSETTS STATE LOTTERY COMMSSION

Disclosure Statement Instructions: Companies seeking to provide professional services (the “engagement”) to the Massachusetts State Lottery Commission (“MSLC”) must complete a disclosure statement providing complete and accurate responses to the questions below. Companies selected to provide such services have a continuing obligation to update responses to these questions, in writing, immediately upon any change to such responses. The questions in this Disclosure Statement should be read broadly, and any perceived ambiguity should be resolved in favor of disclosure. Any questions concerning the disclosures required should be directed to the MSLC.

Note: The total response to this disclosure should not exceed four single-sided pages.

1. Provide a general description of your company’s organizational structure, identify any members of the management committee, officers and/or directors, and, for any affiliate entities, the managing partners, officers, and directors (all such individuals or entities hereinafter collectively referred to as the “Company”).

[Insert response here.]

2. Identify any relationship of the company, its joint ventures, consultants, lobbyists, subcontractors or third-party contractors that relate in any way to the engagement.

[Insert response here.]

3. Aside from the engagement, describe any services provided by the Company to the Commonwealth.

[Insert response here.]

4. Aside from the services described in response to Question 3, above, describe any services and/or donations provided by the company to the Office of the State Treasurer and Receiver General or any trust, board, commission or authority of which the State Treasurer and Receiver General is a member or trustee by virtue of her office. (A list of such entities is attached as Appendix A to the Disclosure Statement.)

[Insert response here.]

5. Aside from the services and/or donations described in responses to Questions 3 and 4, above, describe any services provided by the company to any of the political subdivisions of the Commonwealth.

[Insert response here.]

6. Did or will the company provide or share, agree to provide or share, or arrange to provide or share any compensation or benefit, direct or indirect, to any individual or entity for assisting the company in:

a) Obtaining the engagement; or

b) Performing the services required by the engagement?

If the answer to Question 6 is “yes,” provide for each the individual or entity:

[Insert response here.]

If the answer to Question 7 is “yes,” provide for each such individual or entity:

[Insert response here.] Signed under the penalties of perjury this _______day of ________________, 2016.

Title: __________________________________________

Appendix to the Disclosure Statement

TREASURER’S PRINCIPAL BOARDS, COMMISSIONS AND AUTHORITIES*

1. Advisory Board to the Comptroller – M.G.L. c. 7A, § 2

2. State Retirement Board – M.G.L. c. 10, § 18

3. State Lottery Commission – M.G.L. c. 10, § 23

4. Board of Bank Incorporation – M.G.L. c. 26, § 5 (Division of Banks and Loan Agencies)

5. Water Pollution Abatement Trust (now known as the Clean Water Trust) – M.G.L. c. 29C, § 2

6. Pension Reserves Investment Management Board – M.G.L. c. 32, § 23(2A)

7. Massachusetts Convention Center Authority – Chapter 190 of the Acts of 1982 § 31-48

8. Massachusetts School Building Authority – M.G.L. c. 70B, §§ 1A & 3A; see also M.G.L. c. 10, § 35BB

9. Teachers’ Retirement Board – M.G.L. c. 15, § 16

10. Alcoholic Beverages Control Commission – M.G.L. c. 10, § 70

11. Health Care Security Trust – M.G.L. c. 29D, § 4

12. Commissioners on Fireman’s Relief – M.G.L. c. 10, § 21

13. Economic Empowerment Trust Fund – M.G.L. c. 10, § 35QQ

* The above-listed Boards, Commissions or Authorities are any which are a Treasury Department, Division or Affiliated Entity or by statute have a position which may be held by the State Treasurer and Receiver General or her designee.