Attachment L MSLC Disclosure Statement.doc

COMMONWEALTH OF MASSACHUSETTS

STATE LOTTERY COMMISSION’S DISCLOSURE STATEMENT

Acrylic Dispensers and Displays ASK "RFR Number/Document Number" \* MERGEFORMAT COMMBUYS Bid Number: BD-15-1062-LOT-00001-00000002489 - RFR LOT Number 1505

VENDOR:

ADDRESS:

Vendors seeking to provide goods or services (the “engagement”) to the Commonwealth of Massachusetts State Lottery Commission (“MSLC”) must complete a disclosure statement providing complete and accurate responses to the questions below. Vendor(s) 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’s General Counsel.

1.

Describe in detail your company’s organizational structure, and identify any controlling stockholders, parents, subsidiaries, affiliates, partners, general partners, or principals (all such individuals or entities hereinafter collectively referred to as the “company.”)

2.

Identify any relationship of the company, its joint ventures, consultants, lobbyists, subcontractors, agents, or placement agents that relate in any way to the engagement.

3.

Aside from the engagement, describe any services provided by the company to the MSLC.

4.

Aside from the services described in response to question no. 3, above, describe any services provided by the company to the Office of the Treasurer or any trust, board, commission or authority of which the Treasurer is a member or trustee. (A list of such entities is attached).

5.

Aside from the services described in response to question nos. 3 and 4, above, describe any services provided by the company to the Commonwealth of Massachusetts or any of its political subdivisions.

Page 1 of 3 ATTACHMENT L 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 firm in:

a) obtaining the engagement; or,

b) performing the services required by the engagement.

If the answer to question no. 6 is “yes,” provide for each the individual or entity

a) the name and address of such individual or entity;

b) a description of the assistance provided; and

c) the compensation or benefit.

7.

Does the company have any ongoing relationship, arrangement or agreement with any individual or entity with respect to sharing compensation for services to:

a)

MSLC;

b) any trust, board, commission, or authority of which the Treasurer is a member or trustee; or

c) Massachusetts or its political subdivisions?

If the answer to question no. 7 is “yes,” provide for each such individual or entity

a) the name and address of such individual or entity;

b) a description of the relationship, arrangement or agreement; and,

c) the compensation shared.

Signed under the penalties of perjury on this ___ day of ______________, 2012.

Name:

Signature:

Title:

Page 2 of 3 ATTACHMENT L

Treasurer’s Principal Boards, Commissions, and Authorities

1) Finance Advisory Board– M.G.L. c.6, §§ 97-8

2) State Comptroller’s Advisory Board– M.G.L. c.5A, §2

3) Investment Advisory Council– M.G.L. c.10, §5B

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

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

6) Emergency Finance Board– M.G.L. c.10, §47

7) Board of Bank Incorporation– M.G.L. c.26, §5

8) Water Pollution Abatement Trust– M.G.L. c.29, §2

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

10) Massachusetts Convention Center Authority– Chapter 190 of the Acts of 1982 §§31-48

ATTACHMENT L

Acrylic Dispensers and Displays ASK "RFR Number/Document Number" \* MERGEFORMAT COMMBUYS Bid Number: BD-15-1062-LOT-00001-00000002489 - RFR LOT Number (#) 1505.