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Optional: Additional <br />facts — e.g., why <br />there is a low risk of <br />undue favoritism or <br />improper influence. <br />WRITE AN X TO CONFIRM THE STATEMENT BELOW. <br />If you cannot confirm <br />this statement, Taking into account the facts that I have disclosed above, Ifeel that I can perform my <br />you should official duties objectively and fairly. <br />recuse yourself. <br />Employee sig nature: <br />Date: <br />Attach additional pages if necessary. <br />Not elected to your public position — file with your appointing authority. <br />Elected state or county employees — file with the State Ethics Commission. <br />Members of the General Court — file with the House or Senate clerk or the State Ethics Commission. <br />Elected municipal employee — file with the City Clerk or Town Clark. <br />Elected regional school committee member — file with the clerk or secretary of the committee. <br />Form revised July, 2012 <br />