disclosures: 032f504d05fcaeee9ba0232751be0ce9a0f88a02d4d475401378962428cfaf0c

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id	filename	year	name	title	agency	content
032f504d05fcaeee9ba0232751be0ce9a0f88a02d4d475401378962428cfaf0c	2015/SohnIvy_1.pdf	2015	Ivy E. Sonn MD			DISCLOSURE BY STATE EMPLOYEE OF A FINANCIAL INTEREST IN A CONTRACT TO PROVIDE SERVICES FOR THE COMMITTEE FOR PUBLIC COUNSEL SERVICES AS REQUIRED BY 930 CMR 6.06(2) STATE EMPLOYEE INFORMATION Name of state employee: Ivy E. Sonn MD Title/ Position Please provide information about your state employee position. Assistant Professor, university f inpissachusetts Medical School serving & child avez psychiamst for DMH contract undorsa Agency. University of Massachusetts Medical School Agency address: University of Massa chugtts Medical School Department of Psythiatry 55 North Lake Avenue worester. MA 01655 Office phone: (478) 863-5034 Office e-mail: ivy.sohn@mussmail.state.ma.us I am a state employee. The Committee for Public Counsel Services ("CPCS") provides representation and services to persons with regard to various matters in the state courts and assigns attorneys and personnel to work on the matters. In connection with these matters, I expect to provide representation or services to, or on behalf of, such persons, attorneys or personnel. I respectfully request written approval of the arrangement from CPCS and (If 1 am not an elected state employee) from my appointing authority In my state position. CPCS SERVICES Describe the nature of the representation or Forensic psychalry evaluations. services you expect to provide to or for CPCS. If you are providing services through a company, please provide its name and address, Who will pay you for your services? CPCS, directly. An attorney or personnel assigned by CPCS. If not CPCS, please provide the name and address of the person or entity who will pay you or your company for your services. What is your financial Please explain your financial Interest and provide the dollar amount If you know it. interest In providing these services? I will be compansated for forensic psychiatic sences Please Include both rendcred on an hourly basis compensation and obligations, etc. Employee signature: APPROVAL BY COMMITTEE FOR PUBLIC COUNSEL SERVICES Name and title of CPCS employee giving approval LISA m Hawitt General Counsel Office phone 617-910-5717 Office e-mail LHAWITT 0 Poblic Counsel net Signature by By signing here, I indicate that have reviewed the facts that the state employee has disclosed CPCS employee above and approve the arrangement proposed by the state employee. Date: Jise h Healt 2-23-17 FOR NON-ELECTED STATE EMPLOYEES ONLY: APPROVAL BY APPOINTING AUTHORITY AT STATE AGENCY WHICH YOU SERVE Name and title of appointing authority, or Douglas M. Ziedonis, MD, MPH his or her designee, at the state agency which PROFESSOR and Chair you serve university umass of Massachusetts Medical School Dept. of Memorial PSYCHIATRY Medical Center and Office phone Office e-mail dulas.2iedon1s@LmAssMeMorial.oRg Signature by By signing here, I indicate that I have reviewed the facts that the state employee has disclosed appointing authority Date: above MiD418/15 and approve the arrangement proposed by the state employee. Attach additional pages If necessary. File copy with: State Ethice Commission One Ashburton Place, Room 619 Boston, MA 02108 Form revised March, 2013	2015/SohnIvy_1.pdf