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| 39340 | 2013/Staff_Grancharor4.8.13.pdf | March 2013 TO whom it may Concern STATE RECEIVED ETHICS COMMISSION 2013 APR -8 AM 10: 59 Attached IS a Disclosure by State Employee of Financial Interest (pursant to 930 CMR 6.07). Please confirm receipt of form by email. Email to Vanessa.Staff@State.MA.US. or Vstaff@gmail. Thank you, Vanessa Staff Grancharov Department of Developmental Services 181 North Street Hyannis, MA 02601 508 790-6106 Vanessa. Staff@state MA.US DISCLOSURE BY STATE EMPLOYEE OF FINANCIAL INTEREST IN A CONTRACT TO PROVIDE SOCIAL SERVICES PURSUANT TO 930 CMR 6.07 STATE EMPLOYEE INFORMATION RECEIVEMISSION Name of state Vanessa Staff Grancharov STATE employee: 2013 APR -8 AM11:00 Title/ Position: Clerk IV Agency/Department: Department of Developmental Services Agency Address: 181 North Street Hyannis, MA 02601 Office phone: 508.771.2595 Office e-mail Vanessa.Staff@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 state agencies; or - To provide educational services to 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. I will be a PCA for an individual. The EOHHS pays for the Individual's PCA services. RECEIVEMMISSION Please describe the STATE Please provide information about the type of personal or educational services you will provide. services you will provide. Please do not include the name of any individual 2013 who APR receives services. I will be providing personal services for the individual. The personal services will include daily living and cleaning, such as food preparation and laundry. I will also be interacting at a social level. The individual enjoys doing puzzles, watching old Westerns and going shopping. The individual is a social butterfly and often attends community events throughout the year. I will accompany the individual to various events as needed. What will you be Please include a dollar amount, if possible. paid, or what other I will be paid about $12 per hour - 8 hours every other weekend / 16 hours per month financial interest will you have? Employee signature Vanessa Grancharor Date: 3/7/13 APPROVAL BY AGENCY YOU SERVE AS A STATE EMPLOYEE Name and title of appointing authority Office phone Office e-mail 508-866-8871 rick.omeara@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. Date: APPROVAL BY AGENCY THAT MADE THE CONTRACT (IF DIFFERENT) Name and title of person giving Danzes approval at the state agency that made The Arc of cape COD the contract PCA surrogate . Office phone 771-6595 X114 Office e-mail Cora 60 comcast net Signature by person By signing here, I indicate that I have reviewed the facts that the state employee has giving approval disclosed and approve the arrangement proposed by the state employee. Date: 3.13.13 Attach additional pages if necessary. File with: State Ethics Commission One Ashburton Place, Room 619 Boston, MA 02108 |