PERAC Memo #1 - 1997: Disclosure Statements
Disclosure Statements
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This memo introduces a revised, consolidated PERAC Disclosure Statement that merges the former Disclosure Statement and Brokerage Disclosure Statement into a single form with the same questions. Going forward, PERAC will only accept this standardized PERAC-generated form (and its Acknowledgement) — vendor- or third-party-generated versions will not be accepted. Boards must copy the attached forms and distribute them to vendors providing or seeking to provide services, ensuring vendors complete every question (with attachments as needed) and boards complete the corresponding Acknowledgement.
Full Text
PERAC MEMO #1/1997 M E M O R A N D U M TO:All Retirement Boards FROM:John J. McGlynn, Executive Director RE:Disclosure Statements DATE:January 6, 1997 Attached please find a revised Disclosure Statement and Disclosure Statement Acknowledgement. This revised Disclosure Statement combines the previous Disclosure Statement and Brokerage Disclosure Statement into one form. The questions on this revised Disclosure Statement are identical to those contained in the Disclosure Statement and Brokerage Disclosure Statement. It is, therefore, no longer necessary for vendors to complete the Brokerage Disclosure Statement and for the board to complete the Brokerage Disclosure Statement Acknowledgement. Please be advised that it will be the policy of PERAC to accept only PERAC Disclosure Statement and Disclosure Statement Acknowledgement forms. Vendors must provide a response to each question on the PERAC form and, if necessary, should include attachments. PERAC will not accept Disclosure Statement or Disclosure Statement Acknowledgement forms that have been generated by any other source. Boards should make copies of the attached forms and send them to vendors as needed /rc Attachments
DISCLOSURE STATEMENT Name of Retirement Board: _______________________________________________________________________ Name of Individual or Entity (Hereinafter referred to as the vendor): ______________________________________
It is required that this disclosure statement be completed and signed, under the penalties of perjury, by any vendor either providing services or products or seeking to provide services or products to the Board, including but not limited to investment, actuarial, consulting, counseling, and other retirement related services. 1)Is the above-named vendor presently making or receiving and has the above-named vendor made or received payments, remuneration, reciprocal influence, or any thing of value in connection with obtaining, soliciting, or retaining clients or prospective clients? YES_____ NO_____ If yes, state policy below (please attach additional page(s) if necessary):
2)Is the above-named vendor presently making or receiving and has the above-named vendor made or received payments, remuneration, reciprocal influence or any thing of value in connection with obtaining, soliciting, or retaining business with or from any of the 107 retirement boards established pursuant to G.L. c. 32? YES_____ NO_____ If yes, state policy below (please attach additional page(s) if necessary):
PERAC DS1296
3)Is the above-named vendor presently making or receiving and has the above-named vendor made or received payments, remuneration, reciprocal influence, or any thing of value in whatever form in connection with the development of products or services to be marketed to pension funds? YES_____ NO_____ If yes, state policy below (please attach additional page(s) if necessary):
4)Is the above-named vendor presently making or receiving and has the above-named vendor made or received payments, remuneration, reciprocal influence, or any thing of value in whatever form in connection with the development of products to be marketed to any of the 107 retirement boards established pursuant to G.L. c. 32? YES_____ NO_____ If yes, state policy below (please attach additional page(s) if necessary):
5)Has any person or entity not employed by the above-named vendor offered to assist said individual or entity in marketing its services or products, to any of the 107 retirement boards established pursuant to G.L. c. 32? YES_____ NO_____ If yes, provide below the name and address of person or entity: NAME____________________________________________ ADDRESS____________________________________________
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6)Has any person or entity not employed by the above-named vendor offered to assist in the development of products or services to be marketed to any of the 107 retirement boards established pursuant to G.L. c. 32; YES_____ NO_____ If yes, provide below the name and address of person or entity: NAME____________________________________________ ADDRESS____________________________________________
7)Has the above-named vendor solicited any person or entity to assist the individual or entity in marketing the services or products of the individual or entity, to any of the 107 retirement boards established pursuant to G.L. c. 32? YES_____ NO_____ If yes, provide below the name and address of person or entity: NAME____________________________________________ ADDRESS____________________________________________
8)Has the above-named vendor solicited any person or entity to assist in the development of products or services to be marketed to any of the 107 retirement boards established pursuant to G.L. c. 32? YES_____ NO_____ If yes, provide below the name and address of person or entity: NAME____________________________________________ ADDRESS____________________________________________
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9)Have there been payments, remuneration, reciprocal influence, or any thing of value in whatever form, provided to others or received in connection with the marketing of any services or any product to any of the 107 retirement boards established pursuant to G.L. c. 32? YES_____ NO_____ If yes, provide below the name and address of such person or entity as well as a detailed statement of such transactions: NAME____________________________________________ ADDRESS____________________________________________
STATEMENT OF TRANSACTION (please attach additional page(s) if necessary).
10)Have there been payments, remuneration, reciprocal influence, or any thing of value in whatever form, provided to others or received in connection with the development of a product or a service to be marketed to any of the 107 retirement boards established pursuant to G.L. c. 32? YES_____ NO_____ If yes, provide below the name and address of such person or entity as well as a detailed statement of such transactions: NAME____________________________________________ ADDRESS____________________________________________
STATEMENT OF TRANSACTION (please attach additional page(s) if necessary).
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11)Does the above-named vendor have an arrangement regarding the use of “soft dollar”, “directed brokerage”, “cash rebate”, “commission recapture” programs or any other similar arrangement regarding brokerage generated by the Board's account? YES_____ NO_____ If yes, state policy below. (Please attach additional page(s) if necessary.)
12)Does the above-named vendor have an arrangement with regard to the use of “soft dollar”, “directed brokerage”, “cash rebate”, “commission recapture” or similar arrangement with any Board established by G.L. c. 32? YES_____ NO_____ If yes, provide a detailed statement of the terms and conditions of said arrangement or arrangements. (Please attach additional pages if necessary.)
DATE: NAME OF INDIVIDUAL OR ENTITY: __________________________________________ PRINT OR TYPE NAME: _____________________________________________________ I attest that under the penalties of perjury that the above statements are true. PRINT OR TYPE NAME:_____________________________________________ SIGNATURE:_____________________________________________ TITLE:_____________________________________________ -5- PERAC DS1296
DISCLOSURE STATEMENT ACKNOWLEDGEMENT Name of Individual/Entity Filing Disclosure Statement ______________________________________________________________ Retirement Board ______________________________________________________________ We, the board members and executive officer, acknowledge receipt of the Disclosure Statement filed by the above-named person or entity. We have reviewed the Disclosure Statement and have taken whatever actions, if any, necessary to clarify said Disclosure Statement. Furthermore, we fully understand its content and the responses contained therein. We attest that the above statement is made under the penalties of perjury. DATE: Exec. Secretary/Board Administrator
Ex-Officio Member
Appointed Member
Elected Member
Elected Member
Appointed Member PERAC DSA1296