disclosures: 0123d823c927138b6153f5b5b1fd7e6105de61944a25a0159d008febf6c032be
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| 0123d823c927138b6153f5b5b1fd7e6105de61944a25a0159d008febf6c032be | 2015/Giroux,_Melissa_12.28.15.pdf | 2015 | melissa GiRoux | Department of TRUNSITIONAL Assistance | DISCLOSURE BY STATE EMPLOYEE OF FINANCIAL INTEREST RECEIVED IN A CONTRACT TO PROVIDE SOCIAL SERVICES TATE ETHICS COMMISSION PURSUANT TO 930 CMR 6.07 2015 DEC 28 AM IO: 23 STATE EMPLOYEE INFORMATION Name of state employee: melissa GiRoux Title/ Position: Benefits eligibility Referred Societ worker ( ) ) Agency/Department: Department of TRUNSITIONAL Assistance Agency Address: 95 Linerty St springfieu) MA 01103 Office phone: (413)858-1032 Office e-mail melisa.GIROGY@MUSSMaiL.StaTe.MA.US I am a state employee, and I seek to have a financial interest in a contract or agreement made by a state agency listed below, or by a provider or organization funded by a state agency listed below: A state agency within the following Executive Offices: Executive Office of Health and Human Services, including the Human Service Transportation Office: Executive Office of Public Safety and Security. Executive Office of Elder Affairs, Executive Office of Veteran's Services, or A sheriff's office. The purpose of the contract is: To provide personal services to a person or persons who receive services from, or have services paid for by, these stale agencies: or To provide educational services lo people who work for these state agencies or for providers or organizations funded by these state agencies. I seek approval of the arrangement from the agency for which I serve as a state employee and from the state agency above that made the contract. FINANCIAL INTEREST IN A CONTRACT WITH A STATE AGENCY PLEASE CHECK OFF ONE OF THE THREE STATEMENTS BELOW AND PROVIDE THE REQUESTED INFORMATION. 1) Service to a state agency I will provide personal or educational services to a state agency listed above. Please identify the state agency and also the Executive Office it is in, if applicable. 2) Service to a provider or I will provide personal or educational services to a provider or organization funded by a state organization agency listed above. Please provide the name and address of the provider or organization. Please identify the state agency that funds the provider or organization, and also the Executive Office it is in, if applicable. 3) Service to a person or persons I will provide personal services directly to a person or persons who receive services from, or have services paid for by. a state agency listed above. Please identify the state agency that provides services to, or pays for services for, the person or persons, and also the Executive Office it Is in, if applicable. MassHealTH Please describe the Please provide information about the type of personal or educational services you will provide. services you will Please do not Include the name of any Individual who receives services. provide. I am a THeRapist at west cerinal family & counseling - - 103 Myken st, west springfield, MA 01089. I previde psycho - THeRapy TO patients. Psycitatherapy is What will you be paid, or what other Please include a dollar amount, if possible. often funders by State OR private INSURance companies. financial interest will you have? paiD TU west central Emily & counseling (MASSHealtH OR Meijirake) Payment is Employee signature Meliser GUNY Date: 11-14-15 APPROVAL BY AGENCY YOU SERVE AS A STATE EMPLOYEE Name and title of appointing authority THOMAS G. MASSIMO Office phone 617 - 348 - 8493 Office e-mail THOMAS.MASSIMO@STATE.MA.US Signature by By signing here, I indicate that I have reviewed the facts that the state employee has appointing authority disclosed above and approve the arrangement proposed by the state employee. a Date: 12/4/15 APPROVAL BY AGENCY THAT MADE THE CONTRACT (IF DIFFERENT) Name and title of person giving approval at the state Amarda Cassel Kraft, chief of staff agency that made the contract Office phone 617-593-1738 Office e-mail anaunda.casselkraft@statena.us Signature by person By signing here, 1 indicate that 1 have reviewed the facts that the state employee has giving approval disclosed above and approve the arrangement proposed by the state employee. Amade Carl Katt Date: 12/14/15 Attach additional pages if necessary. File with: State Ethics Commission One Ashburton Place, Room 619 Boston, MA 02108 Form revised February, 2012 | 2015/Giroux,_Melissa_12.28.15.pdf |