2016 ACT 44 Disclosure Form for Entities Providing

Professional Services to the

Tidioute Borough’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 Tidioute Borough (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 December 16, 2016.  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 December 16, 2016.  

RETURN COMPLETED

DISCLOSURE TO:                    Tidioute Borough

                                                Attn: Crystal Heenan, Chief Admistrative Officer (CAO)

                                                129 Main Street

                                                Tidioute, PA 16351

                                                 (814) 484-7424

                                             CAO’s E-mail Address: tboro@tidioute.org

Required Updates:

Where noted, information in this form must be updated in writing as changes occur.

Definitions for Disclosure

List of Municipal Officials for the Requesting Municipality

Contractors:  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 referred to as the “List of Municipal Officials.”

Municipality:  Enter below, a list of municipal officials that have any involvement in the administration or management of the pension system – Elected Officials, Appointed Officials and Employees, Board Members, or other Pension Committee Members (if applicable).  Do not include employees that are not in a management position or serve on a pension committee or in a decision-making position relative to this pension system.  If a category listed below is not applicable, so state.

Identification of Contractors & Related Personnel

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”:                 Non- Uniform Plan                  Police Plan

Fire Plan

**NOTE:  For all that follow, you may answer the questions / items on a separate sheet of paper and attach it to this Disclosure if the space provided is not sufficient.  Please reference each question / item you are responding to by the appropriate number.  (example:  REF – Item #1.)

1.       Please provide the names and titles of all individuals providing professional services to the Requesting Municipality’s pension plan(s) identified above.  Also, include the names and titles of any advisors and subcontractors of the Contractor, identifying them as such.  After each name provide a description of the responsibilities of that person with regard to the professional services being provided to each designated pension plan.

2.       Please list the name and title of any Affiliated Entity and their Executive-level Employee(s) that require disclosure; after each name, include a brief description of their duties.  (See: Definitions)

3.       Are any of the individuals named in Item 1 or Item 2 above, a current or former official or employee of the Requesting Municipality?

           IF “YES”, provide the name of the person employed, their position with the municipality, and dates of

       employment.  

4.       Are any of the individuals named in Item 1 or Item 2 above a current or former registered Federal or State lobbyist?

          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. 

NOTICE:  All information provided for items 1- 4 above must be updated as changes occur.

5.        Since December 17^th 2009, has the Contractor or an Affiliated Entity  paid compensation to or employed any third party intermediary, agent, or lobbyist that is 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 in connection with any transaction or investment involving the Contractor and the Municipal Pension System of the Requesting Municipality?   

This question does not apply 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 intermediary, 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.

6.       Since December 17^th 2009, has the Contractor, or any agent, officer, director or employee of the Contractor solicited a contribution to any municipal officer or candidate for municipal office in the Requesting 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 municipal officials, candidates, political party or political committee who were solicited (to whom the solicitation was made).

7.       Within the past two years:  Has the Contractor or an Affiliated Entity made any contributions to a municipal official or any candidate for municipal office in the Requesting Municipality?

    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 Contractor or an Affiliated Entity have any direct financial, commercial or business relationship with any official identified on the List of Municipal Officials, of the Requesting Municipality?

   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. 

9.       Since December 17^th, 2009:  Has the Contractor or an Affiliated Entity given any gifts having more than a nominal value to any official, employee or fiduciary – specifically, those on the List of Municipal Officials of the Requesting Municipality?

            IF “YES”, Provide the 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 18^th 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.

      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 (or the political entity / 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:

Are 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.

Verification

I, __________________________, hereby state that I am ____________________________ for
                   (Name)                                                                                (Position)

_____________________________________and I am 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 Tidioute Borough 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 unsworn falsification to authorities.

                                                                       _
Signature                                                                                   __________________
Date

Instructions for Municipality:                    DO NOT include this instruction page with the disclosure

You will need to prepare and send one of these disclosure forms to each Contractor that you have a contract for providing services to your pension plan (AND) a separate set of disclosures for each type of plan – fire, police, etc.  

IF ONE CONTRACTOR services two or more plans, then only one disclosure is required, but the contractor must indicate he / she is completing the disclosure for more than one plan…. PAGE 4, Question One.

You should also prepare a brief cover letter explaining the reason you are sending this disclosure out.  

Ø Who should receive this disclosure?

Generally, there are 5 primary service providers for each pension plan but it is not limited to just these:

 Actuarial Services Investment Services         Administration Services              Advisory Services

Legal Advisory Services – usually performed by the municipal solicitor

 IF some of these services are combined through one service provider or Contractor, then you only need to send this to that one entity.   For Example, your administrative services and actuarial services are conducted through Robert Smith and Associates and your contract is with this company.  However, Robert Smith and Associates subcontracts certain portions of these services to two other companies.  You need only send one disclosure to Robert Smith and Associates, and one to any other entity that provides specific services – other than administrative and actuarial.     

Ø PLEASE CHECK WITH YOUR SOLICITOR….as a precaution regarding whom you should send this disclosure to.

Every place you see this: [ Enter Name of Municipality ]  Enter the name of the municipality. Change the Font color to Black and remove the brackets.

Pages 1, 3, and 8 are the only pages that require modification and reprinting by the Municipality.

Instructions for the “Requesting Municipality” for completion of PAGE 3:

Under the header, prepare a list of Names and Positions of all personnel that are a party to ANY Pension Plan the municipality has. This should include:  every Elected Official, Municipal Manager or equivalent position, Municipal Finance Director or equivalent position, Chief Administrative Officer for each plan, The Solicitor, Any Pension Advisory Committee or Pension Board Members (not listed above)