THE FOLLOWING PAGES MUST BE RETURNED TO HUMAN RESOURCES. CITS Logon Application WANT TO GO GREEN?

Transcription

1 New Hire Checklist THE FOLLOWING PAGES MUST BE RETURNED TO HUMAN RESOURCES. Page # Description 2 & 3 New Employee Personal Data Form 4 & 5 Mandatory OBRA Forms 6 Statement Concerning Social Security 8 CITS Logon Application 9 & 10 Employment Application 11 & 12 Form I 9 21 State Ethics Online Training Acknowledgement 22 Receipt of Summary of the Conflict of Interest Law 49 Intellectual Property Policy WANT TO GO GREEN? You only need to print & return pages: 1-6, 8-10, 11-12, 21-22, 49 Updated 2/27/15

2 2 NEW EMPLOYEE/NEW ASSIGNMENT PERSONAL DATA FORM For Temporary/Non-Benefited Positions Employee ID: Epaf #: 7KLV DSSRLQWPHQW LV FRQWLQJHQW XSRQ D VXFFHVVIXO EDFNJURXQG FKHFN Name Last Home Address Home Phone First MI Street ( City Social Security Number State Campus Location Campus Phone ) Date of Birth Gender Military Status: No Military service Active Reserve Zip M Vietnam Era Veteran Retired Veteran F Marital Status Married Veteran other than Vietnam Inactive Reserve Single Disabled Veteran Citizenship Status: US Naturalized Permanent Resident Alien Non - Resident Alien Visa Type: J1 Exchange Student H1B Temp Worker Speciality VISA Expiration Date: _ Student IM Immigrant F1 Ethnicity: Are you Hispanic or Latino? Yes No Indicate one or more races/origins that apply: American Indian or Alaskan Native Asian from Indian subcontinent All other Asian descent Portuguese White (including Middle East) Native Hawaiian or other Pacific Islanders Cape Verdean African American Other Black(including Africa and Caribbean) Highest Education Level: MD, DDS,JD Some Grad school Some College Doctorate Bachelor Technical School IN CASE OF EMERGENCY PLEASE NOTIFY: Name Address Post Doctoral Associate / 2 Year College High School Grad Master of Fine Arts Master all others Less Than High School Grad Phone # Relationship to Employee City State Zip Are you currently receiving a pension, disability pension or retirement allowance from the Commonwealth or from any country, city, town or district in the Commonwealth? If yes, you will be required to complete the Post Retirement Employment Statement of Earnings form. I understand that this position is temporary. As a temporary employee, I understand that I am not eligible for any benefits, unless otherwise indicated. UMass Dartmouth expressly reserves the right to discontinue this appointment at any time without prior notice. In the event of such discontinuance, I understand I shall receive compensation for work performed to date. I-9 ELIGIBILITY FOR EMPLOYMENT MUST BE VERIFIED WITHIN THREE DAYS OF EMPLOYMENT. THIS IS A CONDITION OF EMPLOYMENT. Signature Date TO BE COMPLETED BY THE DEAN/DEPARTMENT HEAD Title Start Date End Date Bi-weekly Stipend $ Dept Name & # Or HRS per week Supervisor Name Note: Temporary Position are authorized on a fiscal year basis Combo Code $ or % Encumb Amt thrgh June 30 Combo Code $ or % Encumb Amt as of July 1st Combo Code $ or % Encumb Amt thrgh June 30 Combo code $ or % Encumb Amt as of July 1st Hourly Rate $ Supervisor Empl ID Signature: Department Head/Chairperson / Date / / Dean/Division head / Date

3 3 FOR HR/PAYROLL USE ONLY: Job Code: HH0100 Accountant HH0300 Info Tech Professional HH0800 Artists HH1200 Engineers HH1400 Health & Safety HH1600 Researchers/Post Doc HH1900 Mngmt Consultant D_ NBFAC Workgroup: D_NBSAL Deduct ESU Agency Fee HH2300 Prgm Coordinator HJ0400 Art Models HJ0500 Athletic Officials HJ2000 Guides/Drivers HJ2500 Lab Serv HJ3300 Photographic Serv HJ4000 Security Services HJ4600 Temp Clerical Services HJ5000 Instructor/Lecturer Trainer HJ5800 Librarians/Archivists HJ6000 Licensed Trades people HJ6109 Depart Assistant DA2109 PTL DA2110 PCE Instructor Taskgroup: D_NBHRLY HR Date Comments Payroll Date FTE Fiscal Date I-9 Date ORA Date UM_EXP UM_POS Guidelines for Emergency Hires 1. If vacant position that will be posted, then posting must take place within six(6) months. 2. All emergency hires must have an EEO waiver that delineates the nature of the emergency. 3. If not a vacant position, but a temporary emergency, then EEO waiver is still required and the temporary appointment will be limited to less than one year and may not be renewed without HR and EEO approval. EEO waiver received? Vacancy to be Posted? Temporary Emergency? (Not due to a vacancy) This Section to be Completed by Human Resources Is this a bargaining unit position? Yes Faculty Federation ESU AFSCME SEIU IBPO No If ESU, Date of Union Notification This Section to be Completed by Employee ESU AGENCY FEE DEDUCTION AUTHORIZATION I hereby authorize and direct the University of Massachusetts Board of Trustees, through its officers, agents and employees, to deduct from the portion of my salary due me each month, the amount as certified by the UMass Faculty Federation, Local 1895, at the current rate of agency fee (for non-members). Such deduction is to start immediately after the date of this authorization. I further authorize and direct you to transfer and pay the sum deducted to the Treasurer of the UMASS Faculty Federation, Local 1895, University Of Massachusetts Dartmouth, North Dartmouth, Massachusetts. Signature Date

4 4 Participant Enrollment Governmental 457(b) Plan Massachusetts Deferred Compensation SMART Plan - Mandatory OBRA Participant Information Last Name First Name MI Social Security Number Address - Number & Street City ( State ) Home Phone ( Address Zip Code ) Work Phone Married Mo Unmarried Day Year Female Mo Day Male Year Date of Birth Date of Hire Do you have a retirement savings plan with a previous employer? Yes or No Important Notice: Employees participating in the Massachusetts Deferred Compensation SMART Plan - OBRA Mandatory Plan (the Plan) must complete Social Security Form SSA The Plan has been designated as an alternative retirement system for part time employees not covered by their employers retirement system. The SSA-1945 explains the potential effects of the Windfall Elimination Provision and Government Pension Offset Provision under the Social Security law which may reduce the amount of your Social Security retirement or disability benefits, and/or benefits received by you as a spouse or an ex-spouse. If you have any questions regarding SSA-1945 or if you have not completed SSA-1945, please contact your employer. Statement Delivery - Participant quarterly statements are sent regular mail via the U.S. Postal Service. If you prefer an environmentally friendly alternative, please visit for fast and easy enrollment in our Online File Cabinet service. Payroll Information To be completed by Representative: Division Name Division Number Investment Option Information (applies to all contributions) - Please refer to your communication materials for information regarding each investment option. I understand that funds may impose redemption fees on certain transfers, redemptions or exchanges if assets are held less than the period stated in the fund s prospectus or other disclosure documents. I will refer to the fund s prospectus and/or disclosure documents for more information. INVESTMENT INVESTMENT OPTION NAME OPTION CODE (Internal Use Only) The Income Fund...MELINC % Form 1 GWRS FENRAP /28/11 Page 1 of 2 ][ ][ GP22 / ][ ][ ][ ][ ADMIN FORMAT A01: ][

5 5 Last Name First Name MI Social Security Number Plan Beneficiary Designation This designation is effective upon execution and delivery to Service Provider at the address below. I have the right to change the beneficiary. If any information is missing, additional information may be required prior to recording my beneficiary designation. If my primary and contingent beneficiaries predecease me or I fail to designate beneficiaries, amounts will be paid pursuant to the terms of the Plan Document or applicable state law. You may only designate one primary and one contingent beneficiary on this form. However, the number of primary or contingent beneficiaries you name is not limited. If you wish to designate more than one primary and/or contingent beneficiary, do not complete the section below. Instead, complete and forward the Beneficiary Designation form. Primary Beneficiary % % of Account Balance Social Security Number Primary Beneficiary Name Relationship Date of Birth Contingent Beneficiary % % of Account Balance Social Security Number Contingent Beneficiary Name Relationship Date of Birth Participation Agreement Withdrawal Restrictions - I understand that the Internal Revenue Code (the "Code") and/or my employer s Plan Document may impose restrictions on transfers and/or distributions. I understand that I must contact the Plan Administrator/Trustee to determine when and/or under what circumstances I am eligible to receive distributions or make transfers. Compliance With Plan Document and/or the Code - Participation in this Plan is mandatory. A deduction will be taken from your wages and invested on your behalf based on your employer s Plan Document. I agree that my employer or Plan Administrator/Trustee may take any action that may be necessary to ensure that my participation in the Plan is in compliance with any applicable requirement of the Plan Document and/or the Code. I understand that the maximum annual limit on contributions is determined under the Plan Document and/or the Code. I understand that it is my responsibility to monitor my total annual contributions to ensure that I do not exceed the amount permitted. If I exceed the contribution limit, I assume sole liability for any tax, penalty, or costs that may be incurred. Incomplete Forms - I understand that in the event my Participant Enrollment form is incomplete or is not received by Service Provider at the address below prior to the receipt of any deposits, I specifically consent to Service Provider retaining all monies received and allocating them to the default investment option. Account Corrections - I understand that it is my obligation to review all confirmations and quarterly statements for discrepancies or errors. Corrections will be made only for errors which I communicate within 90 calendar days of the last calendar quarter. After this 90 days, account information shall be deemed accurate and acceptable to me. If I notify Service Provider of an error after this 90 days, the correction will only be processed from the date of notification forward and not on a retroactive basis. Your Consent and Signature - I have completed, understand and agree to all pages of this Participant Enrollment form. I understand that Service Provider is required to comply with the regulations and requirements of the Office of Foreign Assets Control, Department of the Treasury ("OFAC"). As a result, Service Provider cannot conduct business with persons in a blocked country or any person designated by OFAC as a specially designated national or blocked person. For more information, please access the OFAC Web site at: Deferral agreements must be entered into prior to the first day of the month that the deferral will be made. I verify that this enrollment was unsolicited. I did not meet with a representative on a one-on-one basis regarding investment options. Participant Signature Date Participant forward to Service Provider at: Great-West Retirement Services P.O. Box Denver, CO Phone #: Fax #: Web site: Form 1 GWRS FENRAP /28/11 Page 2 of 2 ][ ][ GP22 / ][ ][ ][ ][ ADMIN FORMAT A01: ][

6 6 Social Security Administration Statement Concerning Your Employment in a Job Not Covered by Social Security Employee Name Employee ID# Employer Name UMass Dartmouth Employer ID# Your earnings from this job are not covered under Social Security. When you retire, or if you become disabled, you may receive a pension based on earnings from this job. If you do, and you are also entitled to a benefit from Social Security based on either your own work or the work of your husband or wife, or former husband or wife, your pension may affect the amount of the Social Security benefit you receive. Your Medicare benefits, however, will not be affected. Under the Social Security law, there are two ways your Social Security benefit amount may be affected. Windfall Elimination Provision Under the Windfall Elimination Provision, your Social Security retirement or disability benefit is figured using a modified formula when you are also entitled to a pension from a job where you did not pay Social Security tax. As a result, you will receive a lower Social Security benefit than if you were not entitled to a pension from this job. For example, if you are age 62 in 2013, the maximum monthly reduction in your Social Security benefit as a result of this provision is $ This amount is updated annually. This provision reduces, but does not totally eliminate, your Social Security benefit. For additional information, please refer to Social Security Publication, Windfall Elimination Provision. Government Pension Offset Provision Under the Government Pension Offset Provision, any Social Security spouse or widow(er) benefit to which you become entitled will be offset if you also receive a Federal, State or local government pension based on work where you did not pay Social Security tax. The offset reduces the amount of your Social Security spouse or widow(er) benefit by two-thirds of the amount of your pension. For example, if you get a monthly pension of $600 based on earnings that are not covered under Social Security, two-thirds of that amount, $400, is used to offset your Social Security spouse or widow(er) benefit. If you are eligible for a $500 widow(er) benefit, you will receive $100 per month from Social Security ($500 $400=$100). Even if your pension is high enough to totally offset your spouse or widow(er) Social Security benefit, you are still eligible for Medicare at age 65. For additional information, please refer to Social Security Publication, Government Pension Offset. For More Information Social Security publications and additional information, including information about exceptions to each provision, are available at You may also call toll free , or for the deaf or hard of hearing call the TTY number , or contact your local Social Security office. I certify that I have received Form SSA-1945 that contains information about the possible effects of the Windfall Elimination Provision and the Government Pension Offset Provision on my potential future Social Security Benefits. Signature of Employee Form SSA-1945 ( ) Destroy Prior Editions Date

7 7 Information about Social Security Form SSA-1945 Statement Concerning Your Employment in a Job Not Covered by Social Security New legislation [Section 419(c) of Public Law , the Social Security Protection Act of 2004] requires State and local government employers to provide a statement to employees hired January 1, 2005 or later in a job not covered under Social Security. The statement explains how a pension from that job could affect future Social Security benefits to which they may become entitled. Form SSA-1945, Statement Concerning Your Employment in a Job Not Covered by Social Security, is the document that employers should use to meet the requirements of the law. The SSA-1945 explains the potential effects of two provisions in the Social Security law for workers who also receive a pension based on their work in a job not covered by Social Security. The Windfall Elimination Provision can affect the amount of a worker s Social Security retirement or disability benefit. The Government Pension Offset Provision can affect a Social Security benefit received as a spouse, surviving spouse, or an ex-spouse. Employers must: Give the statement to the employee prior to the start of employment; Get the employee s signature on the form; and Submit a copy of the signed form to the pension paying agency. Social Security will not be setting any additional guidelines for the use of this form. Copies of the SSA-1945 are available online at the Social Security website, Paper copies can be requested by at [email protected] or by fax at The request must include the name, complete address and telephone number of the employer. Forms will not be sent to a post office box. Also, if appropriate, include the name of the person to whom the forms are to be delivered. The forms are available in packages of 25. Please refer to Inventory Control Number (ICN) when ordering. Form SSA-1945 ( )

8 8 Computing & Information Technology Services UMass Dartmouth Logon Application Return to: Access Management Library 320 (508) Name: Department: Phone #: Building: Room: Please fill in appropriate box: FACULTY Title: Dept: Staff Title: Dept: Affiliate Title: Dept: SIGNATURE: Required reading: For UMass Dartmouth CITS use only: Logon ID: HR ID: Created By: Date: Sponsor: DATE:

9 9 EMPLOYMENT APPLICATION FORM University of Massachusetts Dartmouth Date: Office of Human Resources Foster Administration Building # Old Westport Road North Dartmouth, MA (508) You may attach a resume. However, you must complete all questions AND sign at the bottom of Page 2. We are an equal opportunity and affirmative action employer. We do not discriminate on the basis of an individual s race, color, age, religion, gender, sexual orientation, national origin, mental or physical disability, marital status, veteran status, political belief or affiliation in accordance with University policy, state and federal law as it applies to employment, admission to and participation in the University s programs and activities, provision of services, and selection of vendors who provide services or products to the University. Name (First-Middle-Last): If your employment/education records are under any other name(s), please specify: Street Address: City: State: Home Phone: Zip Code: Work Phone: Address: Cell Phone: May we contact you at work? Yes No Position applied for: Availability Date: Shift: Full Time Days Benefited Evenings Part-time Nights Temporary Any Shift Names of relatives currently employed at the University: If no, indicate immigration status: No Are you legally authorized to work in the United States? Yes NOTE: Proof of identity and right to work in the United States must be presented within 72 hours of the date of hire. School High School Name and Address of School Degree or Diploma No Yes Type: Community College 4 yr. College/ University 4 yr. College/ University Graduate School No Yes Type: No Yes Type: No Yes Type: No Yes Type: Other (Specify) No Yes Type: Major Professional licenses and registrations: Type: Reg. no: Date expires: State: Type: Date expires: State: Reg. no: Have you ever been employed by the Commonwealth of Massachusetts, including UMASS Dartmouth? Yes If yes, give dates: No Are you now receiving or are you eligible to receive a monthly retirement allowance or pension check from the Commonwealth of No Massachusetts, or a county, city, town or political subdivision within Massachusetts? Yes

10 10 Prior Work Experience: List all prior work experience beginning with the present or most recent employer. You may include any military or voluntary service. You may attach resume to this Form. From: Name of Organization: To: No. and Street: Current Salary: City, State, Zip: Position Title: Supervisor: Number of hours worked per week: Major duties: Reason for Leaving: From: Name of Organization: To: No. and Street: Current Salary: City, State, Zip: Position Title: Supervisor: Number of hours worked per week: Major duties: Reason for Leaving: You may attach additional sheets or substitute a resume for Prior Work Experience information. READ CAREFULLY BEFORE SIGNING. ALL CANDIDATES MUST SIGN THIS APPLICATION FORM. I understand and agree that, as a condition of employment at the University of Massachusetts Dartmouth, I may be required to pay monthly union dues or a monthly agency fee under the provisions of existing collecting bargaining agreements. I understand and agree that any offer of employment is conditional upon being authorized to work in the United States and upon the completion of an I-9 Form within 72 hours of employment. I understand and agree that I may be required to pass a job related physical examination or other job related assessments as a condition of employment. I fully understand and authorize the University of Massachusetts Dartmouth to investigate and confirm any and all statements or claims made by me in this application, in supplementary documents and materials, and in interviews. I fully understand and authorize my current and former employers and references to release any and all information related to my employment, job performance, work history, education and training. I fully understand and authorize any police or investigative agent to release any and all information related to my criminal background. I fully understand and agree to release from liability or penalty and agree not to bring legal action against any employee or agent of the University, any employee or agent of a former employer, any references, or any police or investigative agent, for the collection, release, use or dissemination of information obtained in the University s investigation and review. I understand that the University of Massachusetts Dartmouth is a drug free, smoke free, violence free and harassment free work environment. I understand that this application applies only to the position I have listed and that consideration for any other positions require the filing of another application. I acknowledge that all past service with the Commonwealth of Massachusetts, state agency, municipality, and/or University of Massachusetts Dartmouth is accurate and complete. I declare that all statements on this application, supplementary documents and materials, and in interviews are true and correct to the best of my knowledge and belief, and any misrepresentation or false information, if discovered before my employment will be just cause for my rejection, and if discovered after my employment will be just cause for my dismissal from the University of Massachusetts Dartmouth. SIGNATURE OF APPLICANT

11 11 Employment Eligibility Verification USCIS Form 1-9 Department of Homeland Security OMB No Expires 03/31/2016 U.S. Citizenship and Immigration Services ~START HERE. Read Instructions carefully before completing this form. The Instructions must be available during completion of this form. ANTI-DISCRIMINATION NOTICE: It is illegal to discriminate against work-authorized individuals. Employers CANNOT specify which document(s) they will accept from an employee. The refusal to hire an individual because the documentation presented has a future expiration date may also constitute illegal discrimination. Section 1. Employee Information and Attestation (Employees must complete and sign Section 1 of Form 1-9 no later than the first day of employment, but not before accepting a job offer.) Last Name (Family Name) First Name (Given Name) Address (Street Number and Name) Date of Birth (mm/ddlyyyy) Apt. Number Middle Initial Other Names Used (if any) City or Town State U.S. Social Security Number Address D-O-I Zip Code Telephone Number 1 I am aware that federal law provides for imprisonment andlor fines for false statements or use of false documents in connection with the completion of this form. I attest, under penalty of perjury, that I am (check one of the following): D A citizen of the United States D A noncitizen national of the United States (See instructions) D A lawful permanent resident (Alien Registration Number/USCIS Number): D An alien authorized to work until (expiration date, if applicable, mm/dd/yyyy). Some aliens may write "N/A" in this field. (See instructions) For aliens authorized to work, provide your Alien Registration Number/USCIS Number OR Form 1-94 Admission Number: 1. Alien Registration Number/USCIS Number: 3-D Barcode Do Not Write In This Space OR 2. Form 1-94 Admission Number: If you obtained your admission number from CBP in connection with your arrival in the United States, include the following: Foreign Passport Number: Country of Issuance: Some aliens may write "N/A" on the Foreign Passport Number and Country of Issuance fields. (See instructions) ISignature of Employee: IDate (mm/ddlyyyy): Preparer and/or Translator Certification (To be completed and signed if Sect/on 1 is prepared by a person other than the employee.) I attest, under penalty of perjury, that I have assisted in the completion of this form and that to the best of my knowledge the information is true and correct. Signature of Pre parer or Translator: Last Name (Family Name) Address (Street Number and Name) Date (mmidd/yyyy): First Name (Given Name) City or Town State Zip Code Employer Completes Next Page Form /08/13 N Page 7 of9

12 12 Section 2. Employer or Authorized Representative Review and Verification (Employers or their authorized representative must complete and sign Section 2 within 3 business days of the employee's first day of employment. You must physically examine one document from List A OR examine a combination of one document from List B and one document from List C as listecf on the "Lists of Acceptable Documents" on the next page of this form. For each document you review, record the following information: document title, issuing authority, document number, and expiration date, if any.) Employee Last Name, First Name and Middle Initial from Section 1: List A OR Identity and Employment Authorization AND List B List C Identity Employment Authorization Document Title: Document Title: Document Title: Issuing Authority: Issuing Authority: Issuing Authority: Document Number: Document Number: Document Number: Expiration Date (if any)(mmldd1ww): Expiration Date (if any)(mmlddlww): Expiration Date (if any)(mmlddlywy): Document Title: Issuing Authority: Document Number: Expiration Date (if any)(mmlddlywy): 3 0 Barcode Do Not Write in This Space Document Title: Issuing Authority: Document Number: Expiration Date (if any)(mmlddlywy): Certification I attest, under penalty of perjury, that (1) I have examined the document(s) presented by the above-named employee, (2) the above-listed document(s) appear to be genuine and to relate to the employee named, and (3) to the best of my knowledge the employee is authorized to work in the United States. The employee's first day of employment (mm/dd/yyyy)' Signature of Employer or Authorized Representative Last Name (Family Name) (See instructions for exemptions) I Title of Employer or Authorized Representative Date (mmlddlwyy) First Name (Given Name) Employer's Business or Organization Name University of Massachusetts Dartmouth Employer's Business or Organization Address (Street Number and Name) City or Town 285 Old Westport Road Section 3. Reverification and Rehires State Dartmouth MA Zip Code (To be completed and signed by employer or authorized representative.) A. New Name (if applicable) Last Name (Family Name) First Name (Given Name) I Middle Initial B. Date of Rehire (if applicable) (mmlddlww): C. If empioyee's previous grant of employment authorization has expired, provide the information for the document from List A or List C the employee presented that establishes current employment authorization in the space provided below. Document Title: Document Number: Expiration Date (if any)(mmldd/ywy): I attest, under penalty of perjury, that to the best of my knowledge, this employee is authorized to work in the United States, and if the employee presented document(s), the document(s) I have examined appear to be genuine and to relate to the individual. Signature of Employer or Authorized Representative: Form /08/13 N Date (mmldd/yyw): Print Name of Employer or Authorized Representative: Page 8 of9

13 Page 3 13

14 14 Instructions for Employment Eligibility Verification Department of Homeland Security U.S. Citizenship and Immigration Services USCIS Form 1-9 OMB No Expires 03/ Read all instructions carefully before completing this form. Anti-Discrimination Notice. It is illegal to discriminate against any work-authorized individual in hiring, discharge, recruitment or referral for a fee, or in the employment eligibility verification (Form 1-9 and E-Verify) process based on that individual's citizenship status, immigration status or national origin. Employers CANNOT specify which document(s) they will accept from an employee. The refusal to hire an individual because the documentation presented has a future expiration date may also constitute illegal discrimination. For more information, call the Office of Special Counsel for Immigration-Related Unfair Employment Practices (OSC) at (employees), (employers), or (TOO), or visit www Jy~ti~~gov/crt/about/~>-sc. IWhat Is the Purpose of This Form? Employers must complete Form 1-9 to document verification of the identity and employment authorization of each new employee (both citizen and noncitizen) hired after November 6, 1986, to work in the United States. In the Commonwealth of the Northern Mariana Islands (CNMI), employers must complete Form 1-9 to document verification of the identity and employment authorization of each new employee (both citizen and noncitizen) hired after November 27, Employers should have used Form 1-9 CNMI between November 28,2009 and November 27,2011. IGeneral Instructions Employers are responsible for completing and retaining Form 1-9. For the purpose of completing this form, the term "employer" means all employers, including those recruiters and referrers for a fee who are agricultural associations, agricultural employers, or farm labor contractors. Form 1-9 is made up of three sections. Employers may be fined if the form is not complete. Employers are responsible for retaining completed forms. Do not mail completed forms to U.S. Citizenship and Immigration Services (USCIS) or Immigration and Customs Enforcement (ICE). ISection 1. Employee Information and Attestation Newly hired employees must complete and sign Section 1 of Form 1-9 no later than the first day of employment. Section 1 should never be completed before the employee has accepted a job offer. Provide the following information to complete Section 1: N arne: Provide your full legal last name, first name, and middle initial. Your last name is your family name or surname. If you have two last names or a hyphenated last name, include both names in the last name field. Your first name is your given name. Your middle initial is the first letter of your second given name, or the first letter of your middle name, if any. Other names used: Provide all other names used, if any (including maiden name). If you have had no other legal names, write "NI A." Address: Provide the address where you currently live, including Street Number and Name, Apartment Number (if applicable), City, State, and Zip Code. Do not provide a post office box address (P.O. Box). Only border commuters from Canada or Mexico may use an international address in this field. Date of Birth: Provide your date of birth in the mm/ddlyyyy format. For example, January 23, 1950, should be written as 01123/1950. U.S. Social Security Number: Provide your 9-digit Social Security number. Providing your Social Security number is voluntary. However, if your employer participates in E-Verify, you must provide your Social Security number. Address and Telephone Number (Optional): You may provide your address and telephone number. Department of Homeland Security (DHS) may contact you if DHS learns of a potential mismatch between the information provided and the information in DHS or Social Security Administration (SSA) records. You may write "NIA" if you choose not to provide this information. Form 1-9 Instructions 03/ N EMPLOYERS MUST RETAIN COMPLETED FORM 1-9 DO NOT MAIL COMPLETED FORM 1-9 TO ICE OR USCIS Page 1 of9

15 15 All employees must attest in Section 1, under penalty of perjury, to their citizenship or immigration status by checking one ofthe following four boxes provided on the form: 1. A citizen of the United States 2. A noncitizen national ofthe United States: Noncitizen nationals of the United States are persons born in American Samoa, certain former citizens of the former Trust Territory of the Pacific Islands, and certain children of noncitizen nationals born abroad. 3. A lawful permanent resident: A lawful permanent resident is any person who is not a U.S. citizen and who resides in the United States under legally recognized and lawfully recorded permanent residence as an immigrant. The term "lawful permanent resident" includes conditional residents. If you check this box, write either your Alien Registration Number (A-Number) or USCIS Number in the field next to your selection. At this time, the USCIS Number is the same as the A-Number without the "A" prefix. 4. An alien authorized to work: If you are not a citizen or national of the United States or a lawful permanent resident, but are authorized to work in the United States, check this box. If you check this box: a. Record the date that your employment authorization expires, ifany. Aliens whose employment authorization does not expire, such as refugees, asylees, and certain citizens ofthe Federated States of Micronesia, the Republic of the Marshall Islands, or Palau, may write "NI A" on this line. b. Next, enter your Alien Registration Number (A-Number)IUSCIS Number. At this time, the USCIS Number is the same as your A-Number without the "A" prefix. If you have not received an A-NumberIUSCIS Number, record your Admission Number. You can find your Admission Number on Form 1-94, "Arrival-Departure Record," or as directed by US CIS or U.S. Customs and Border Protection (CBP). (1) If you obtained your admission number from CBP in connection with your arrival in the United States, then also record information about the foreign passport you used to enter the United States (number and country of issuance). (2) If you obtained your admission number from USCIS within the United States, or you entered the United States without a foreign passport, you must write "NIA" in the Foreign Passport Number and Country of Issuance fields. Sign your name in the "Signature of Employee" block and record the date you completed and signed Section 1. By signing and dating this form, you attest that the citizenship or immigration status you selected is correct and that you are aware that you may be imprisoned and/or fined for making false statements or using false documentation when completing this form. To fully complete this form, you must present to your employer documentation that establishes your identity and employment authorization. Choose which documents to present from the Lists of Acceptable Documents, found on the last page of this form. You must present this documentation no later than the third day after beginning employment, although you may present the required documentation before this date. Preparer and/or Translator Certification The Preparer and/or Translator Certification must be completed if the employee requires assistance to complete Section 1 (e.g., the employee needs the instructions or responses translated, someone other than the employee fills out the information blocks, or someone with disabilities needs additional assistance). The employee must still sign Section 1. Minors and Certain Employees with Disabilities (Special Placement) Parents or legal guardians assisting minors (individuals under 18) and certain employees with disabilities should review the guidelines in the Handbook/or Employers: Instructions/or Completing Form 1-9 (M-274) on ww\v.usc.i~!govl I-9Centrul before completing Section 1. These individuals have special procedures for establishing identity if they cannot present an identity document for Form 1-9. The special procedures include (1) the parent or legal guardian filling out Section 1 and writing "minor under age 18" or "special placement," whichever applies, in the employee signature block; and (2) the employer writing "minor under age 18" or "special placement" under List B in Section 2. Form 1-9 Instructions 03/08113 N Page 2 of9

16 16 Section 2. Employer or Authorized Representative Review and Verification Before completing Section 2, employers must ensure that Section 1 is completed properly and on time. Employers may not ask an individual to complete Section 1 before he or she has accepted ajob offer. Employers or their authqrized representative must complete Section 2 by examining evidence of identity and employment authorization within 3 business days of the employee's first day of employment. For example, if an employee begins employment on Monday, the employer must complete Section 2 by Thursday of that week. However, if an employer hires an individual for less than 3 business days, Section 2 must be completed no later than the first day of employment. An employer may complete Fonn 1-9 before the first day of employment if the employer has offered the individual ajob and the individual has accepted. Employers cannot specify which document(s) employees may present from the Lists of Acceptable Documents, found on the last page offonn 1-9, to establish identity and employment authorization. Employees must present one selection from List A OR a combination of one selection from List B and one selection from List C. List A contains documents that show both identity and employment authorization. Some List A documents are combination documents. The employee must present combination documents together to be considered a List A document. For example, a foreign passport and a Fonn 1-94 containing an endorsement of the alien's nonimmigrant status must be presented together to be considered a List A document. List B contains documents that show identity only, and List C contains documents that show employment authorization only. If an employee presents a List A document, he or she should not present a List B and List C document, and vice versa. If an employer participates in E-Verify, the List B document must include a photograph. In the field below the Section 2 introduction, employers must enter the last name, first name and middle initial, if any, that the employee entered in Section 1. This will help to identify the pages of the fonn should they get separated. Employers or their authorized representative must: 1. Physically examine each original document the employee presents to detennine if it reasonably appears to be genuine and to relate to the person presenting it. The person who examines the documents must be the same person who signs Section 2. The examiner of the documents and the employee must both be physically present during the examination of the employee's documents. 2. Record the document title shown on the Lists of Acceptable Documents, issuing authority, document number and expiration date (if any) from the original document(s) the employee presents. You may write "N/A" in any unused fields. If the employee is a student or exchange visitor who presented a foreign passport with a Fonn 1-94, the employer should also enter in Section 2: a. The student's Fonn 1-20 or DS-2019 number (Student and Exchange Visitor Infonnation System-SEVIS Number); and the program end date fromfonn 1-20 or DS Under Certification, enter the employee's first day of employment. Temporary staffing agencies may enter the first day the employee was placed in ajob pool. Recruiters and recruiters for a fee do not enter the employee's first day of employment. 4. Provide the name and title of the person completing Section 2 in the Signature of Employer or Authorized Representative field. 5. Sign and date the attestation on the date Section 2 is completed. 6. Record the employer's business name and address. 7. Return the employee's documentation. Employers may, but are not required to, photocopy the document(s) presented. If photocopies are made, they should be made for ALL new hires or reverifications. Photocopies must be retained and presented with Fonn 1-9 in case of an inspection by DHS or other federal government agency. Employers must always complete Section 2 even ifthey photocopy an employee's document(s). Making photocopies of an employee's document(s) cannot take the place of completing Fonn 1-9. Employers are still responsible for completing and retaining Fonn 1-9. Form 1-9 Instructions 03/08/13 N Page 3 of9

17 17 Unexpired Documents Generally, only unexpired, original documentation is acceptable. The only exception is that an employee may present a certified copy of a birth certificate. Additionally, in some instances, a document that appears to be expired may be acceptable if the expiration date shown on the face of the document has been extended, such as for individuals with temporary protected status. Refer to the Handbook/or Employers: Instnlctions/or Completing Form 1-9 (M-274) or 1-9 Central ( for examples. Receipts If an employee is unable to present a required document (or documents), the employee can present an acceptable receipt in lieu of a document from the Lists of Acceptable Documents on the last page ofthis form. Receipts showing that a person has applied for an initial grant of employment authorization, or for renewal of employment authorization, are not acceptable. Employers cannot accept receipts if employment will last less than 3 days. Receipts are acceptable when completing Form 1-9 for a new hire or when reverification is required. Employees must present receipts within 3 business days of their first day of employment, or in the case of reverification, by the date that reverification is required, and must present valid replacement documents within the time frames described below. There are three types of acceptable receipts: 1. A receipt showing that the employee has applied to replace a document that was lost, stolen or damaged. The employee must present the actual document within 90 days from the date of hire. 2. The arrival portion of Form 1-94/I-94A with a temporary stamp and a photograph ofthe individual. The employee must present the actual Permanent Resident Card (Form 1-551) by the expiration date of the temporary stamp, or, ifthere is no expiration date, within 1 year from the date of issue. 3. The departure portion of Form 1-94/I-94A with a refugee admission stamp. The emp10yee must present an unexpired Employment Authorization Document (Form 1-766) or a combination of a List B document and an unrestricted Social Security card within 90 ~ays. When the employee provides an acceptable receipt, the employer should: 1. Record the document title in Section 2 under the sections titled List A, List B, or List C, as applicable. 2. Write the word "receipt" and its document number in the "Document Number" field. Record the last day that the receipt is valid in the "Expiration Date" field. By the end of the receipt validity period, the employer should: 1. Cross out the word "receipt" and any accompanying document number and expiration date. 2. Record the number and other required document information from the actual document presented. 3. Initial and date the change. See the Handbook/or Employers: Instmctions/or Completing Form 1-9 (M-274) at for more information on receipts. Section 3. Reverification and Rehires Employers or their authorized representatives should complete Section 3 when reverifying that an employee is authorized to work. When rehiring an employee within 3 years of the date Form 1-9 was originally completed, employers have the option to complete a new Form 1-9 or complete Section 3. When completing Section 3 in either a reverification or rehire situation, if the employee's name has changed, record the name change in Block A. For employees who provide an employment authorization expiration date in Section 1, employers must reverify employment authorization on or before the date provided. Fonn I-9 Instructions 03/08113 N Page 4 of9

18 18 Some employees may write "N/A" in the space provided for the expiration date in Section 1 if they are aliens whose employment authorization does not expire (e.g., asylees, refugees, certain citizens of the Federated States of Micronesia, the Republic of the Marshall Islands, or Palau). Reverification does not apply for such employees unless they chose to present evidence of employment authorization in Section 2 that contains an expiration date and requires reverification, such as Form 1-766, Employment Authorization Document. Reverification applies if evidence of employment authorization (List A or List C document) presented in Section 2 expires. However, employers should not reverify: 1. U.S. citizens and noncitizen nationals; or 2. Lawful permanent residents who presented a Permanent Resident Card (Form 1-551) for Section 2. Reverification does not apply to List B documents. Ifboth Section 1 and Section 2 indicate expiration dates triggering the reverification requirement, the employer should reverify by the earlier date. For reverification, an employee must present unexpired documentation from either List A or List C showing he or she is still authorized to work. Employers CANNOT require the employee to present a particular document from List A or List C. The employee may choose which document to present. To complete Section 3, employers should follow these instructions: 1. Complete Block A if an employee's name has changed at the time you complete Section Complete Block B with the date of rehire if you rehire an employee within 3 years of the date this form was originally completed, and the employee is still authorized to be employed on the same basis as previously indicated on this form. Also complete the "Signature of Employer or Authorized Representative" block. 3. Complete Block C if: a. The employment authorization or employment authorization document of a current employee is about to expire and requires reverification; or b. You rehire an employee within 3 years of the date this form was originally completed and his or her employment authorization or employment authorization document has expired. (Complete Block B for this employee as well.) To complete Block C: a. Examine either a List A or List C document the employee presents that shows that the employee is currently authorized to work in the United States; and b. Record the document title, document number, and expiration date (if any). 4. After completing block A, B or C, complete the "Signature of Employer or Authorized Representative" block, including the date. For reverification purposes, employers may either complete Section 3 of a new Form 1-9 or Section 3 of the previously completed Form 1-9. Any new pages of Form 1-9 completed during reverification must be attached to the employee's original Form 1-9. If you choose to complete Section 3 ofa new Form 1-9, you may attach just the page containing Section 3, with the employee's name entered at the top of the page, to the employee's original Form 1-9. If there is a more current version of Form 1-9 at the time of reverification, you must complete Section 3 of that version of the form. IWhat Is the Filing Fee? There is no fee for completing Form 1-9. This form is not filed with USCIS or any government agency. Form 1-9 must be retained by the employer and made available for inspection by U.S. Government officials as specified in the "USCIS Privacy Act Statement" below. IUSCIS Forms and Information For more detailed information about completing Form 1-9, employers and employees should refer to the Handbook/or Employers: Instructions/or Completing Form 1-9 (M-274). Form 1-9 Instructions 03/08/13 N Page 5 of9

19 19 You can also obtain information about Form 1-9 from the USCIS Web site at by ing USCIS at or by calling For TDD (hearing impaired), call To obtain US CIS forms or the Handbook/or Employers, you can download them from the USCIS Web site at gov/fanns. You may order USCIS forms by calling our toll-free number at You may also obtain forms and information by contacting the USCIS National Customer Service Center at For TDD (hearing impaired), call Information about E-Verify, a free and voluntary program that allows participating employers to electronically verify the employment eligibility of their newly hired employees, can be obtained from the USCIS Web site at by ing USCIS at [email protected] or by calling For TDD (hearing impaired), call Employees with questions about Form 1-9 and/or E-Verify can reach the USCIS employee hot line by calling For TDD (hearing impaired), call IPhotocopying and Retaining Form 1-9 A blank Form 1-9 may be reproduced, provided all sides are copied. The instructions and Lists of Acceptable Documents must be available to all employees completing this form. Employers must retain each employee's completed Form 1-9 for as long as the individual works for the employer. Employers are required to retain the pages of the form on which the employee and employer enter data. If copies of documentation presented by the employee are made, those copies must also be kept with the form. Once the individual's employment ends, the employer must retain this form for either 3 years after the date of hire or 1 year after the date employment ended, whichever is later. Form 1-9 may be signed and retained electronically, in compliance with Department of Homeland Security regulations at 8 CFR 274a.2. IUSCIS Privacy Act Statement AUTHORITIES: The authority for collecting this information is the Immigration Reform and Control Act of 1986, Public Law (8 USC 1324a). PURPOSE: This information is collected by employers to comply with the requirements of the Immigration Reform and Control Act of This law requires that employers verify the identity and employment authorization of individuals they hire for employment to preclude the unlawful hiring, or recruiting or referring for a fee, of aliens who are not authorized to work in the United States. DISCLOSURE: Submission of the information required in this form is voluntary. However, failure of the employer to ensure proper completion of this form for each employee may result in the imposition of civil or criminal penalties. In addition, employing individuals knowing that they are unauthorized to work in the United States may subject the employer to civil and/or criminal penalties. ROUTINE USES: This information will be used by employers as a record of their basis for determining eligibility of an employee to work in the United States. The employer will keep this form and make it available for inspection by authorized officials of the Department of Homeland Security, Department of Labor, and Office of Special Counsel for Immigration-Related Unfair Employment Practices. IPaperwork Reduction Act An agency may not conduct or sponsor an information collection and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. The public reporting burden for this collection of information is estimated at 35 minutes per response, including the time for reviewing instructions and completing and retaining the form. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: U.S. Citizenship and Immigration Services, Regulatory Coordination Division, Office of Policy and Strategy, 20 Massachusetts Avenue NW, Washington, DC ; OMB No Do not mail your completed Form 1-9 to this address. Fonn 1-9 Instructions 03/08/13 N Page 6 of9

20 20 Memo to Campus Community As a result of Governor Patrick signing into law Chapter 28 of the Acts of 2009, An Act to to Improve the Laws Relating to Campaign Finance, Ethics and Lobbying (the "Bill") on July 1, 2009, employees of the University of Massachusetts Dartmouth must comply with the new mandatory requirements. Summary of the Conflict of Interest Law On or before December 28, 2009, and on an annual basis thereafter, all current state employees must be provided with a summary of the Conflict of Interest Law. Every public employee must sign a written acknowledgement that s/he has received the summary. This summary is accessible on the Human Resources website at Please review the Summary and sign the acknowledgement page and return it to Human Resources. Alternatively, an acknowledging receipt of the summary can be sent to [email protected] Mandatory Online Training Program All current state employees must complete an ethics training program on the Commission's website. State employees will be required to provide a certificate of completion of the training to the Human Resource Department. The link to online training is provided below: *Please note that when multiple users attempt to complete the current online training program using the same computer they may experience a problem accessing the beginning of the training program. To resolve this problem, the user will need to open their Internet browser, then click on "Tools," then "Internet Options," select the "Delete" button under Browsing History, then click on "Delete Cookies" button and confirm delete by clicking on "Yes" then "Close" to close that dialog box, then click "OK". The user should then be able to click back on the Online Training module on the Commission's website and start at the beginning.* There are a total of 25 questions in the quiz. If you do not finish all the questions you will be able to return, on your next visit, to where you left off. Thank you in advance for complying with these new state mandates. If you have any questions, please contact Sue Wilbur at Ext

21 21 State Ethics Commission Online Training The Ethics Reform Bill (Chapter 28 of the Acts of 2009) made changes to the Conflict of Interest Law (M.G.L. Chapter 268A). One of the changes requires that all employees of the University of Massachusetts Dartmouth, including visiting lecturers and temporary employees, complete online training provided by the State Ethics Commission no later than 30 days after day of hire. You can access the online training on the following website: State Ethics Commission After you have completed the online training program, you must print or save the State Ethics Commission Receipt. Mail the printed receipt to the Office of Human Resources or the saved receipt to If you have any questions, please contact Sue Wilbur at or by at ****************************************************************************** I understand that I am required to complete online training provided by the State Ethics Commission no later than 30 days after my date of hire. Employees Name Employees Signature Date

22 22 * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * ACKNOWLEDGMENT OF RECEIPT I,, hereby acknowledge that I (first and last name) received a copy of the summary of the conflict of interest law for state employees on. (date) State employees should complete the acknowledgment of receipt and return it to the Human Resource Department. Alternatively, state employees may send an acknowledging receipt of the summary to [email protected].

23 23 Summary of the Conflict of Interest Law for State Employees This summary of the conflict of interest law, General Laws chapter 268A, is intended to help state employees understand how that law applies to them. This summary is not a substitute for legal advice, nor does it mention every aspect of the law that may apply in a particular situation. State employees can obtain free confidential advice about the conflict of interest law from the Commission s Legal Division. State agency counsel may also provide advice. The conflict of interest law seeks to prevent conflicts between private interests and public duties, foster integrity in public service, and promote the public s trust and confidence in that service by placing restrictions on what state employees may do on the job, after hours, and after leaving public service, as described below. The sections referenced below are sections of G.L. c. 268A. When the Commission determines that the conflict of interest law has been violated, it can impose a civil penalty of up to $10,000 ($25,000 for bribery cases) for each violation. In addition, the Commission can order the violator to repay any economic advantage he gained by the violation, and to make restitution to injured third parties. Violations of the conflict of interest law can also be prosecuted criminally. I. Are you a state employee for conflict of interest law purposes? You do not have to be a full-time, paid state employee to be considered a state employee for conflict of interest purposes. Anyone performing services for a state agency or holding a state position, whether paid or unpaid, including full- and part-time state employees, elected officials, volunteers, and consultants, is a state employee under the conflict of interest law. An employee of a private firm can also be a state employee, if the private firm has a contract with the state and the employee is a key employee under the contract, meaning the state has specifically contracted for her services. The law also covers private parties who engage in impermissible dealings with state employees, such as offering bribes or illegal gifts. II. On-the-job restrictions. (a) Bribes. Asking (See Section 2) for and taking bribes is prohibited. A bribe is anything of value corruptly received by a state employee in exchange for the employee being influenced in his official actions. Giving, offering, receiving, or asking for a bribe is illegal. Bribes are more serious than illegal gifts because they involve corrupt intent. In other words, the state employee intends to sell his office by agreeing to do or not do some official act, and the giver intends to influence him to do so. Bribes of any value are illegal. (b) Gifts and gratuities. Asking for or accepting a gift because of your official position, or because of something you can do or have done in your official position, is prohibited. (See Sections 3, 23(b)(2), and 26)

24 24 State employees may not accept gifts and gratuities valued at $50 or more given to influence their official actions or because of their official position. Accepting a gift intended to reward past official action or to bring about future official action is illegal, as is giving such gifts. Accepting a gift given to you because of the state position you hold is also illegal. Meals, entertainment event tickets, golf, gift baskets, and payment of travel expenses can all be illegal gifts if given in connection with official action or position, as can anything worth $50 or more. A number of smaller gifts together worth $50 or more may also violate these sections. Example of violation: A highway inspector allows a pavement contractor to buy him lunch every day during a two-month road repaving project. Example of violation: An industry association provides a free day s outing, including a barbecue lunch, golf, a cocktail hour, and a clam bake, to a group of legislators. Regulatory exemptions. There are situations in which a state employee s receipt of a gift does not present a genuine risk of a conflict of interest, and may in fact advance the public interest. The Commission has created exemptions, and is considering creating additional exemptions, permitting giving and receiving gifts in these situations. One commonly used exemption permits state employees to accept payment of travelrelated expenses when doing so advances a public purpose. Other exemptions are listed on the Commission s website. Example where there is no violation: A non-profit concerned with preventing domestic violence offers to pay the travel expenses of an assistant district attorney to a conference on prosecuting domestic violence cases. The attorney fills out a disclosure form and obtains prior approval from his appointing authority. (c) Misuse of position. Using your official position to get something you are not entitled to, or to get someone else something they are not entitled to, is prohibited. Causing someone else to do these things is also prohibited. (See Sections 23(b)(2) and 26) A state employee may not use her official position to get something worth $50 or more that would not be properly available to other similarly situated individuals. Similarly, a state employee may not use her official position to get something worth $50 or more for someone else that would not be properly available to other similarly situated individuals. Causing someone else to do these things is also prohibited. Example of violation: A state employee writes a novel on work time, using her office computer, and directing her secretary to proofread the draft. Example of violation: The commissioner of a state agency directs subordinates to drive her wife to and from the grocery store. Example of violation: An assistant attorney general avoids a speeding ticket by asking the police officer who stops him, Do you know who I am? and showing his state I.D. (d) Self-dealing and nepotism. Participating as a state employee in a matter in which you, your immediate family, your business organization, or your future employer has a financial interest is prohibited. (See Section 6)

25 25 A state employee may not participate in any particular matter in which he or a member of his immediate family (parents, children, siblings, spouse, and spouse s parents, children, and siblings) has a financial interest. He also may not participate in any particular matter in which a prospective employer, or a business organization of which he is a director, officer, trustee, or employee has a financial interest. Participation includes discussing as well as voting on a matter, and delegating a matter to someone else. A financial interest may create a conflict of interest whether it is large or small, and positive or negative. In other words, it does not matter if a lot of money is involved or only a little. It also does not matter if you are putting money into your pocket or taking it out. If you, your immediate family, your business, or your employer have or has a financial interest in a matter, you may not participate. The financial interest must be direct and immediate or reasonably foreseeable to create a conflict. Financial interests which are remote, speculative or not sufficiently identifiable do not create conflicts. Neither general legislation nor home rule legislation are particular matters for purposes of the conflict of interest law. A state employee can participate in general legislation and home rule legislation even if she has a financial interest in such legislation, but state legislators and constitutional officers must file a disclosure if the matter will substantially affect their financial interests. Example of violation: The chief administrative officer of a state agency, who has a balance of 900 hours in accumulated sick leave, proposes a plan by which the agency will pay employees for accumulated sick leave. Example of violation: An employee of the Massachusetts Cultural Council is also the director of a nonprofit corporation dedicated to increasing art in public spaces. The non-profit applies to the Council for a grant, and the employee participates in rating the applications received for that grant. Example of violation: A state employee promotes his son to a position under his supervision. Example where there is no violation: Proposed legislation under consideration by the State Senate will amend the General Laws with respect to insurance coverage of ocean front property. A State Senator owns ocean front property in Cape Cod. The Senator can discuss and vote on the legislation because it is general legislation, but must file a disclosure because the legislation will substantially affect her financial interest. A state employee whose duties do not require her to participate in a particular matter may comply with the law by simply not participating in the particular matter in which she has a financial interest. She need not give a reason for not participating. An appointed state employee may also comply with the law by filing a written disclosure about the financial interest with his appointing authority, and seeking permission to participate notwithstanding the conflict. If a state employee s duties would require him to participate in a matter in which he has a financial interest, this is the procedure he should use. The appointing authority may grant written permission to participate if she determines that the financial interest in question is not so substantial that it is likely to affect the integrity of the employee s services to the state. Otherwise, the appointing authority will assign the matter to someone else, or do it herself. Participating without disclosing the financial interest is a violation. Elected employees cannot use the disclosure procedure because they have no appointing authority.

26 26 Example where there is no violation: An appointed member of a state licensing board wishes to participate in board discussions about imposing a continuing education requirement on licensees. Compliance with the proposed requirement will cost every licensee several hundred dollars per year. The board member is himself a licensee. Prior to participating in any board discussion, the member files a disclosure of his financial interest with his appointing authority, and the appointing authority gives him a written determination authorizing his participation, despite his financial interest. (e) False claims. Presenting a false claim to your employer for a payment or benefit is prohibited, and causing someone else to do so is also prohibited. (See Sections 23(b)(4) and 26) A state employee may not present a false or fraudulent claim to his employer for any payment or benefit worth $50 or more, or cause another person to do so. Example of violation: A state agency manager directs his secretary to fill out time sheets to show him as present at work on days when he was skiing. (f) Appearance of conflict. Acting in a manner that would make a reasonable person think you can be improperly influenced is prohibited. (See Section 23(b)(3)) A state employee may not act in a manner that would cause a reasonable person to think that she would show favor toward someone, or that she can be improperly influenced. Section 23(b)(3) requires a state employee to consider whether her relationships and affiliations could prevent her from acting fairly and objectively when she performs her duties for the state. If she cannot be fair and objective because of a relationship or affiliation, she should not perform her duties. However, a state employee, whether elected or appointed, can avoid violating this provision by making a public disclosure of the facts. An appointed employee must make the disclosure in writing to his appointing official. Example where there is no violation: A state agency employee is engaged to be married to the owner of a business. The business owner submits a response to a request for proposals from the agency. A reasonable person could conclude that the employee might favor her fiance s response. The employee files a written disclosure with her appointing authority explaining her relationship with her fiance prior to the meeting at which responses to the RFP will be considered. There is no violation of Section 23(b)(3). Example where there is no violation: The State House of Representatives is considering legislation which will create a general law that sets a maximum limit on insurance premiums paid by obstetricians. A State Representative is married to an obstetrician who will be affected by the proposed legislation. The Representative can participate in the matter but files a disclosure of his wife s interest to eliminate any appearance of a conflict. There is no violation. (g) Confidential information. Improperly disclosing or personally using confidential information obtained through your job is prohibited. (See Section 23(c))

27 27 State employees may not improperly disclose confidential information, or make personal use of non-public information they acquired in the course of their official duties to further their personal interests. III. After-hours restrictions. (a) Taking a second paid job that conflicts with the duties of your state job is prohibited. (See Section 23(b)(1)) A state employee may not accept other paid employment if the responsibilities of the second job are incompatible with his or her state job. Example: A state police trooper may not work as a paid private security guard in the area where he serves because the demands of his private employment would conflict with his duties as a trooper. Example: A State Senator may not take a second position counseling clients on how to receive favorable consideration in the Massachusetts Senate. (b) Divided loyalties. Receiving pay from anyone other than the state to work on a matter involving the state is prohibited. Acting as agent or attorney for anyone other than the state in a matter involving the state is also prohibited whether or not you are paid. (See Section 4) Because the Commonwealth is entitled to the undivided loyalty of its employees, a state employee may not be paid by other people and organizations in relation to a matter in which the state has an interest. In addition, a state employee may not act on behalf of other people and organizations or act as an attorney for other people and organizations if the state has an interest in a matter. Acting as agent includes contacting the state in person, by phone, or in writing; acting as a liaison; providing documents to the state; and serving as spokesman. A state employee may always represent his own personal interests, even before his own state agency or board, on the same terms and conditions that would apply to other similarly situated members of the public. State Senators and State Representatives are not subject to Section 4. However, they may personally appear before state agencies for compensation other than their legislative salaries only on ministerial matters such as filing tax returns, permit and license applications, and incorporation papers, and in state court proceedings and quasi-judicial agency proceedings. Example of violation: A state employee makes inquiries to another state agency about an investigation that the second state agency is conducting of his wife. Example of violation: A state advisory commission member participates in matters at his agency that affect one of his private clients, and is compensated by the client for his work on its behalf. Example where there is no violation: A State Senator is contacted by a constituent who has applied for benefits to a state agency, has not received a timely determination by the agency, and cannot get his calls to the agency returned. The Senator may call the agency on the constituent s behalf to inquire about the

28 28 matter. The Senator s aide may also call the agency on the constituent s behalf to inquire about the matter without violating Section 4. While many state employees earn their livelihood in state jobs, some state employees volunteer their time to the state or receive small stipends. Others may serve in a part-time state position which permits them to have other personal or private employment during normal working hours. In recognition of the need not to unduly restrict the ability of volunteers and part-time employees to earn a living, the law is less restrictive for these special state employees than for other state employees. If a state position is a special state position, an employee holding that position may be paid by others, act on behalf of others, and act as attorney for others with respect to matters before state agencies other than his own, provided that he has not officially participated in the matter, and the matter is not now, and has not within the past year been, under his official responsibility, and is not pending before his own state agency. Example: A part-time investigator for a state agency may work on her own time privately for a party litigating a case with a different state agency, provided that she has not participated in or had responsibility for the litigated matter in her state position. (c) Inside track. Being paid by the state, directly or indirectly, under some second arrangement in addition to your job is prohibited, unless an exemption applies. (See Section 7) A state employee generally may not have a financial interest in a state contract, including a second state job. A state employee is also generally prohibited from having an indirect financial interest in a contract that the state has with someone else. This provision is intended to prevent state employees from having an inside track to further financial opportunities. Example of violation: A state employee accepts paid employment with a second state agency. Example of violation: A state employee buys a surplus computer from his agency. Example of violation: A state employee wants to work for a non-profit that receives funding under a contract with the state. Unless she can satisfy the requirements of an exemption under Section 7, she cannot take the job. There are numerous exemptions. Some exemptions apply only to special state employees. Specific exemptions may cover State Senators and State Representatives, teaching and related activities in state facilities, providing services to state agency clients, and other specific situations. Please call the Ethics Commission s Legal Division for advice about a specific situation. IV. After you leave state employment. (See Section 5) (a) Forever ban. After you leave your state job, you may never work for anyone other than the state on a matter that you worked on as a state employee.

29 29 If you participated in a matter as a state employee, you cannot ever be paid to work on that same matter for anyone other than the state, nor may you act for someone else, whether paid or not. The purpose of this restriction is to bar former employees from selling to private interests their familiarity with the facts of particular matters that are of continuing concern to the state. The restriction does not prohibit former state employees from using the expertise acquired in government service in their subsequent private activities. Example of violation: A former state employee works for a contractor under a contract that she helped to draft and oversee for the state. (b) One year cooling-off period. For one year after you leave your state job you may not participate in any matter over which you had official responsibility during your last two years of public service. Former state employees are barred for one year after they leave state employment from personally appearing before any agency of the state in connection with matters that were under their authority in their prior state positions during the two years before they left. Example: A state employee negotiates a three-year contract with a company. The manager who supervised the employee, and had official responsibility for the contract but did not participate in negotiating it, leaves her job to work for the company to which the contract was awarded. The former manager may not call or write the state in connection with the company s work on the contract for one year after leaving the state. (c) Partners. Your partners will be subject to restrictions while you serve as a state employee and after your state service ends. Partners of state employees and former state employees are also subject to restrictions under the conflict of interest law. If a state employee participated in a matter, or if he has official responsibility for a matter, then his partner may not act on behalf of anyone other than the state or provide services as an attorney to anyone but the state in relation to the matter. Example: An architect serves on the state Architectural Access Board, and is responsible for every matter that comes before the Board. While he serves, his partners may not submit architectural plans for any clients seeking a variance from the Board. Example: A former state agency general counsel joins a law firm as a partner. Her new partners cannot represent any private clients in connection with matters she litigated for the state for one year after her job with the state ended. Example: A professional engineer formerly employed by a state agency joins an engineering firm organized as a partnership. His new partners cannot appear before his former agency in connection with matters that he worked on for the state for one year after his job with the state ended. (d) Legislative and executive agents. For one year after you leave your state job you may not act as a legislative or executive agent before your former agency.

30 30 Example of violation: The chief of staff of a State Senator leaves his position. Three months later, he contacts his successor to lobby on behalf of a client. * * * * * This summary is not intended to be legal advice and, because it is a summary, it does not mention every provision of the conflict law that may apply in a particular situation. You can find further information about how the law applies in many situations elsewhere on this website. You can also contact the Commission s Legal Division via this website, by telephone, or by letter. Version 3: Revised October 7, 2009

31 31 YOU ARE RECEIVING THIS NOTICE AS REQUIRED BY THE NEW NATIONAL HEALTH REFORM LAW (ALSO KNOWN AS THE AFFORDABLE CARE ACT OR ACA) On January 1, 2014, the Affordable Care Act (ACA) will be implemented in Massachusetts and across the nation. The ACA will bring many benefits to Massachusetts and its residents, helping us expand coverage to more Massachusetts residents, making it more affordable for small businesses to offer their employees healthcare, and providing additional tools to help families, individuals and businesses find affordable coverage. This notice is meant to help you understand health insurance Marketplaces, which are required by the ACA to make it easier for consumers to compare health insurance plans and enroll in coverage. In Massachusetts, the state Marketplace is known as the Massachusetts Health Connector. While you may or may not qualify for health insurance through the Health Connector, it may still be helpful for you to read and understand the information included here. Overview: When key parts of the national health reform law take effect in January 2014, there will be an easy way for many individuals and small businesses in Massachusetts to buy health insurance: the Massachusetts Health Connector. This notice provides some basic information about the Health Connector, and how coverage available through the Health Connector relates to any coverage that may be offered by your employer. You can find out more by visiting: MAhealthconnector.org, or for non-massachusetts residents, Healthcare.gov or ( ; TTY: ). What is the Massachusetts Health Connector? The Health Connector is our state s health insurance Marketplace. It is designed to help individuals, families, and small businesses find health insurance that meets their needs and fits their budget. The Health Connector offers "one-stop shopping" to easily find and compare private health insurance options from the state s leading health and dental insurance companies. Some individuals and families may also qualify for a new kind of tax credit that lowers their monthly premium right away, as well as cost sharing reductions that can lower out-of-pocket expenses. This new tax credit is enabled by 26B of the Internal Revenue Service (IRS) Code. Open enrollment for individuals and families to buy health insurance coverage through the Health Connector begins Oct. 1, 2013, for coverage starting as early as Jan. 1, (And in future years, open enrollment will begin every Oct. 15.) You can find out more by visiting MAhealthconnector.org or calling MA ENROLL ( ). Can I qualify for federal and state assistance that reduces my health insurance premiums and out-of-pocket expenses through the Health Connector? Depending on your income, you may qualify for federal and/or state tax credits and other subsidies that reduce your premiums and lower your out-of-pocket expenses if you shop through the Health Connector. You can find out more about the income criteria for qualifying for these subsidies by visiting MAhealthconnector.org or calling MA ENROLL ( ). Does access to employer-based health coverage affect my eligibility for subsided health insurance through the Health Connector? An offer of health coverage from the Commonwealth of Massachusetts, as the employer, could affect your eligibility for these credits and subsidies through the Health Connector. If your income meets the eligibility criteria, you will qualify for credits and subsidies through the Health Connector if: The Commonwealth of Massachusetts does not offer coverage to you, OR The Commonwealth of Massachusetts offers you coverage, but:

32 32 o o The coverage the Commonwealth of Massachusetts provides you (not including other family members) would require you to spend more than 9.5 percent of your household income for the year; or The coverage the Commonwealth of Massachusetts provides does not meet the "minimum value" standard set by the new national health reform law (which says that the plan offered has to cover at least 60 percent of total allowed costs) If you purchase a health plan through the Health Connector instead of accepting health coverage offered by the Commonwealth of Massachusetts please note that you will lose the employer contribution (if any) for your health insurance. Also, please note that the amount that you and your employer contribute to your employer-sponsored health insurance is often excluded from federal and state income taxes. Health Connector premiums have different tax treatment. As part of considering whether the ACA and Marketplaces will affect you as an employee it is important to understand what the Commonwealth of Massachusetts offers you. The Commonwealth offers benefited employees health coverage through the Group Insurance Commission. To be eligible for GIC health insurance, a state employee must work a minimum of 18 ¾ hours in a 37.5 hour workweek or 20 hours in a 40 hour workweek. The employee must contribute to a participating GIC retirement system, such as the State Board of Retirement, a municipal retirement board, the Teachers Retirement Board, the Optional Retirement Pension System for Higher Education, a Housing, Redevelopment Retirement Plan, or another Massachusetts public sector retirement system (OBRA is not such a public retirement system for this purpose ( Temporary employees, contractors, less-than-half time part time workers, and most seasonal employees are not eligible for GIC health insurance benefits. These employees are offered a Section 125 Plan through the CommonwealthThese plans allow employees the ability to purchase health insurance on a pre-tax basis. This Massachusetts law (956 CMR 4.00, authorized by M.G.L. c. 176Q, 16) requires employers to provide an option for their employees to buy health insurance with pre-tax income, even if those employees do not qualify for a health insurance plan offered by the employer. This is done by setting up a payroll deduction that lets employees make a health insurance premium payment with pre-tax dollars. The Commonwealth s employees can enroll in the Section 125 plan that is administered through Mosaic, Inc. ( If there is any confusion around your employment status and what you are eligible for, please [email protected] or contact your HR department or GIC Coordinator: Office of Human Resources (508) Employer ID # UMass Employer ID #

33 33 Affordable Care Act- Health Insurance Marketplaces Question and Answers 1) Why am I receiving this notice about health insurance marketplaces? The federal Affordable Care Act (ACA) requires that all employees receive this notice to help you understand health insurance Marketplaces, which were set up to make it easier for consumers to compare health insurance plans and enroll in coverage. In Massachusetts, the state Marketplace is known as the Massachusetts Health Connector. When key parts of the national health reform law take effect in January 2014, the Health Connector will provide an easy way for many individuals and small businesses in Massachusetts to buy health insurance. This notice provides some basic information about the Health Connector, and how coverage available through the Health Connector relates to any coverage that may be offered by your employer. You can find out more by visiting: MAhealthconnector.org, for non-massachusetts residents, Healthcare.gov or ( ; TTY: ). 2) What is the ACA provision that requires this notice? The Commonwealth of Massachusetts is required by law ( 1512 of the ACA, which creates 29 U.S.C. 218b) to provide you the information contained in this notice. On January 1, 2014, the Affordable Care Act (ACA) will be implemented in Massachusetts and across the nation. The ACA will bring many benefits to Massachusetts and its residents, helping us expand coverage to more Massachusetts residents, making it more affordable for small businesses to offer their employees healthcare, and providing additional tools to help families, individuals and businesses find affordable coverage. 3) What is the Massachusetts Health Connector? The Health Connector is our state s health insurance Marketplace. It is designed to help individuals, families, and small businesses find health insurance that meets their needs and fits their budget. The Health Connector offers "one-stop shopping" to easily find and compare private health insurance options from the state s leading health and dental insurance companies. Some individuals and families may also qualify for a new kind of tax credit that lowers their monthly premium right away, as well as cost sharing reductions that can lower out-of-pocket expenses. This new tax credit is enabled by 26B of the Internal Revenue Service (IRS) Code. Open enrollment for individuals and families to buy health insurance coverage through the Health Connector begins Oct. 1, 2013, for coverage starting as early as Jan. 1, (And in future years, open enrollment will begin every Oct. 15.) You can find out more by visiting MAhealthconnector.org or calling MAENROLL ( ). 4) Am I eligible for shopping in the Marketplace (the Health Connector)? You may or may not qualify for health insurance through the Health Connector. If you are offered coverage by the Commonwealth of Massachusetts that is considered affordable and meets a minimum value standard according to federal definitions (see below), you most likely will not qualify for the subsidized coverage offered through the Health Connector described in this notice. Most benefitted state employees may not shop for subsidized coverage in the Marketplace; the exception is that some employees who live outside Massachusetts may be eligible. However, it may still be helpful for you to read and understand the information in the notice and Q&As. 5) Can I qualify for federal and state assistance that reduces my health insurance premiums and out-of-pocket expenses through the Health Connector? Depending on your income, you may qualify for federal and/or state tax credits and other subsidies that reduce your premiums and lower your out-of-pocket expenses if you shop through the Health Connector. You can find out more

34 34 about the income criteria for qualifying for these subsidies by visiting the MAhealthconnector.org or by calling 1-877MAENROLL ( ). 6) Does access to employer-based health coverage affect my eligibility for subsided health insurance through the Health Connector? An offer of health coverage from the Commonwealth of Massachusetts could affect your eligibility for these credits and subsidies through the Health Connector. If your income meets the eligibility criteria, you will qualify for credits and subsidies through the Health Connector if: You are not eligible for health benefits through the Commonwealth of Massachusetts in its role as your employer, or You are eligible for health benefits through the Commonwealth of Massachusetts in its role as your employer, but: o o The individual premium for the least expensive health plan for which you are eligible costs more than 9.5 percent of your household income for the year; or The coverage the Commonwealth of Massachusetts provides does not meet the "minimum value" standard set by the new national health reform law (which says that the plan offered has to cover at least 60 percent of total allowed costs). Please note that in 2014, all GIC plans meet minimum value standards. If you purchase a health plan through the Health Connector instead of accepting health coverage offered by the Commonwealth of Massachusetts, please note that you will lose the employer contribution for your health insurance. Also, please note that the amount that you and your employer contribute to your employer-sponsored health insurance is often excluded from federal and state income taxes. 7) Am I eligible for GIC health benefits? The Commonwealth offers benefited employees health coverage through the Group Insurance Commission (GIC). To be eligible for GIC health insurance, a state employee must work a minimum of 18¾ hours in a 37.5 hour workweek or 20 hours in a 40 hour workweek. The employee must contribute to a participating GIC retirement system, such as the State Board of Retirement, a municipal retirement board, the Teachers Retirement Board, the Optional Retirement Pension System for Higher Education, a Housing, Redevelopment Retirement Plan, or another Massachusetts public sector retirement system (OBRA is not such a public retirement system for this purpose ( ). 8) Am I eligible for a Section 125 Plan? Temporary employees, contractors, less-than-part time workers, and most seasonal employees are not eligible for GIC health insurance benefits. These employees must be offered a Section 125 Plan through their employer. These plans allow employees the ability to purchase health insurance on a pretax basis. This Massachusetts law (956 CMR 4.00, authorized by M.G.L. c. 176Q, 16) requires employers to provide an option for their employees to buy health insurance with pre-tax income, even if those employees do not qualify for a health insurance plan offered by the employer. This is done by setting up a payroll deduction that lets workers make a health insurance premium payment with pre-tax dollars. The Commonwealth s employees can enroll in the Section 125 plan that is administered through Mosaic, Inc. ( 9) Who should I contact if I have questions about my employment status, eligibility, or any other information? If you have questions or need further information, send an to [email protected] or contact your HR department or GIC Coordinator: Office of Human Resources (508) Employer ID # UMass Employer ID #

35 Massachusetts Deferred Compensation SMART Plan Mandatory OBRA35 Office of State Treasurer Timothy P. Cahill PARTICIPATE OBRA Information Guide S A V E M O N E Y Basic Facts About OBRA and the Massachusetts Deferred Compensation SMART Plan As a part-time, seasonal or temporary employee of the Commonwealth of Massachusetts or a Massachusetts local government employer, you are required to participate in the Massachusetts Deferred Compensation SMART Plan (SMART Plan). The SMART Plan is an alternative to Social Security as permitted by the federal Omnibus Budget Reconciliation Act of 1990 (OBRA). OBRA, passed by the U.S. Congress, requires that beginning July 1, 1991, employees not eligible to participate in their employer s retirement program be placed in Social Security or another program meeting federal requirements. The SMART Plan meets those federal requirements. Mandatory Contributions As an OBRA employee, you must contribute at least 7.5% of your gross compensation per pay period to the SMART Plan. This contribution is deducted on a pre-tax basis, reducing your current taxable income. This means that you will not pay any tax on this money until it is distributed from your account. Your human resources or payroll center representative will provide you with an OBRA Mandatory Participation Agreement. Please complete and return the form to either your human resources or payroll center representative. Investment Option All mandatory contributions to the SMART Plan will be invested in the Income Fund. The Income Fund is designed to protect your principal and maximize earnings. Your account will earn interest based upon the prevailing rates for this type of investment. Mandatory contributions may not be transferred out of the Income Fund. A N D R E T I R E Additional information regarding the Income Fund may be obtained online at > Invest > Fund Fact Sheets or via the SMART Plan Service Center at (877) Administrative Fee There is a fee of $18.48 per OBRA account, per annum, charged monthly. Fees are used to pay for administrative, recordkeeping, communication and investment education expenses. Voluntary Contributions You may make additional contributions (voluntary contributions) above the mandatory contribution of 7.5% of compensation per pay period. Any voluntary contributions that you elect to make may be invested among the SMART Plan s wide array of investment options and are freely transferable among options in accordance with the terms of the SMART Plan. OBRA voluntary contributions will not be charged an additional administrative fee. T O M O R R O W Through either the Web site or SMART Plan Service Center, you can: Obtain your account balance(s), allocations and transaction history Obtain investment option information and returns Order a new PIN or personalize your PIN Update your beneficiary information as needed Statements You will receive an annual statement in January of each year showing contributions, earnings, fees, distributions and the total value of your account. Please review your statement carefully to ensure your information is correct. It is extremely important that you keep the Plan administrator advised of your current address. To set up voluntary contributions or to learn more, please contact your local SMART Plan Representative at (877) , option 2.2 To update your address, call the SMART Plan Service Center at (877) You can also go to > Find a Form. Click on the link OBRA Mandatory Personal Information Change Request. Mail or fax the completed form to the address or fax number provided on the form. Account Management Distributions Once you are enrolled in the SMART Plan, you will have access to your account 24 hours a day, seven days a week through the Web site at > Account Access or via the SMART Plan Service Center at (877) All you need is your Social Security number (SSN) and Personal Identification Number (PIN). Your PIN will be mailed to your home as soon as you are enrolled in the SMART Plan.3 Upon initial login to the Web site, please enter your SSN in the Username field. For security purposes, you will then be asked to create a personalized Username. Distribution of your SMART Plan benefits can only be made upon: Severance from employment Your death Severance from employment occurs because of your voluntary or involuntary termination of employment. There is no early withdrawal penalty for taking a distribution of your account upon separation of service, regardless of your age. If you

36 36 no longer work for the Commonwealth of Massachusetts or a Massachusetts local government employer, you may take a lump-sum distribution (payable to you or to your beneficiary upon your death) or roll over your assets into another eligible employer-sponsored plan or traditional Individual Retirement Account (IRA). A leave of absence is not a severance from employment. Also, a change from part-time to full-time employment, or any similar change, is not considered an event that could result in a distribution from the SMART Plan. Benefits attributable to your voluntary contribution account may be distributed under other options available under the SMART Plan. You may elect to receive your distribution immediately upon severance from employment. For more information or to access a Distribution Request Form, please contact the SMART Plan Service Center at (877) Beneficiaries and Death If you die before receiving all of your SMART Plan assets, the funds will go to your designated beneficiary. If you do not designate a beneficiary, your funds will be paid to your estate and will be distributed in accordance with Massachusetts probate law. It is essential that you designate a beneficiary on the enrollment form to ensure your assets will pass on as you intended. Paper Go to smart.com > Find a Form. Click on the link OBRA Mandatory Beneficiary Designation. Mail or fax the completed form to the address or fax number provided on the form. You will receive a written confirmation after your beneficiary information has been updated. It is extremely important that you keep the Plan administrator advised of your beneficiary changes. Converting to Full-Time Status If you become a permanent, full-time employee and at one time made contributions to an OBRA mandatory account, you may elect to transfer your OBRA mandatory account to your voluntary account in the SMART Plan. In order to take advantage of this option, you cannot be actively contributing to the OBRA mandatory plan. To implement this change or to learn more, please contact your local SMART Plan Representative at (877) , option 2.2 Service Buyback If you reach a point where you are no longer making OBRA mandatory contributions but you re still working for a Commonwealth of Massachusetts state agency or municipality, you may be eligible for a Service Buyback of your credible years of service to your qualified governmental defined benefit retirement plan. Service Buybacks may be funded from transferred assets from the OBRA mandatory and/or voluntary contribution accounts. More Information To obtain additional information, please call the SMART Plan Service Center at (877) , Monday through Friday, from 9:00 a.m. to 8:00 p.m. Eastern Time. Updating your beneficiary is quick and easy. You have two choices: Online Log in to the SMART Plan Web site at smart.com > Account Access. Then go to My Profile > Update Beneficiary. 1 Access to the SMART Plan Service Center and Web site may be limited or unavailable during periods of peak demand, market volatility, systems upgrades/ maintenance or other reasons. 2 Representatives of GWFS Equities, Inc. are not registered investment advisers, and cannot offer financial, legal or tax advice. Please consult with your financial planner, attorney and/or tax adviser as needed. 3 The account owner is responsible for keeping the assigned PIN confidential. Please contact Great West Retirement Services immediately if you suspect any unauthorized use. Core securities, when offered, are offered through GWFS Equities, Inc., a wholly owned subsidiary of Great West Life & Annuity Insurance Company. Investment options offered through a combination of mutual funds, collective trust funds and separately managed institutional accounts. Great West Retirement Services refers to products and services provided by Great West Life & Annuity Insurance Company and its subsidiaries and affiliates. Great West Retirement Services is a registered service mark of Great West Life & Annuity Insurance Company. All rights reserved. Not intended for use in New York Great West Life & Annuity Insurance Company. Form# CB1096OBRAPH (4/08) P59575

37 37 University of Massachusetts Intellectual Property Policy Dartmouth The prompt and open dissemination of the results of research and creative work among scholars and, eventually, to the public at large is essential to the University's mission of education and research. The commercial development and distribution of the results of research and creative work to benefit the inventor or creator and the economy is part of the University's mission of public service. This Policy is intended to facilitate the commercial development of intellectual property arising at the University and to provide an incentive to University inventors or creators to participate in such development while acknowledging the University's primary goal of the discovery and dissemination of knowledge. I. Definitions As used in this Policy, the following words shall have the following meanings: A. Confidential Information - Information that is received by a Covered Individual from a third party under an express or implied obligation of confidence. B. Covered Individuals - All staff, faculty members, students, adjunct professors in residence, and any other individuals associated with the University. C. Copyrightable Work - A creative work that is protectable under the copyright laws of the United States or other countries. Copyright protection is available for most literary, musical, dramatic, and other types of creative works, including, for example, computer software, teaching materials, multimedia works, proposals, and research reports. D. CVIP - The University Office of Commercial Ventures and Intellectual Property, which has primary responsibility for administering the development and commercialization of Intellectual Property through licensing or other arrangements. E. Director - The Executive Director of the CVIP. F. Evaluation Committee or Committee - One of several University committees, each with a particular area of technical expertise, that advises the CVIP and Vice Chancellor for Research in evaluating Inventions, Tangible Research Materials, and Copyrightable Works. G. Exempted Scholarly Work - A Scholarly Work that falls within certain categories of Copyrightable Works for which academic institutions have historically waived any ownership interest in favor of the author. The University currently recognizes the following categories of Exempted Scholarly Works: textbooks, class notes, classroom presentation and instruction, research articles, research monographs, student theses and dissertations, paintings, drawings, sculpture, musical compositions and performances, dramatic works and performances, poetry, and popular fiction and nonfiction or other works of artistic expression. As modern types of works become clearly established as Scholarly Works, so that individual consideration is no longer deemed necessary, the President may expand this list of Exempted Scholarly Works beyond these historically established categories. As described below, under most circumstances Exempted Scholarly Works need not be disclosed to the University and

38 38 the University automatically waives any ownership interest in such works. H. Intellectual Property - Inventions, Copyrightable Works, and Tangible Research Materials. I. Invention - A discovery or development that may be protectable under the patent laws of the United States, the United States Plant Variety Protection Act, or equivalent laws in other countries. J. Outside Researcher - An individual who performs or directs research for an organization other than the University. K. President - The President of the University or his or her designee. L. Public Disclosure or Publicly Disclosed - Any written or oral disclosure of an Invention or Copyrightable Work to any person not under a contractual or fiduciary obligation of confidentiality to the University. M. Scholarly Work - A Copyrightable Work that has the primary goal of disseminating academic or scholarly knowledge, or is a work of artistic expression. As described below, whether a Copyrightable Work is a Scholarly Work will be determined by the Director and Vice Chancellor for Research on a case-by-case basis (except that Exempted Scholarly Works are automatically considered Scholarly Works), and under most circumstances the University waives all ownership interests in Scholarly Works. N. Tangible Research Materials or Materials - Tangible biological, chemical, and physical materials or equipment. Examples include cell lines, antibodies, DNA or RNA, chemical samples, plasmids, and prototypes. O. Vice Chancellor for Research - The Vice Chancellor for Research at each campus, or where no such person exists, the Provost (or their designees). II. Scope A. Persons Subject to the Policy All Covered Individuals are subject to this Policy. B. Types of Intellectual Property Covered by the Policy This Policy addresses the three categories of Intellectual Property (Inventions, Copyrightable Works, and Tangible Research Materials) as well as Confidential Information. The President shall have authority to designate additional types of Intellectual Property under this Policy. III. Policy 1. Participation Agreement The University has adopted a Participation Agreement, attached as Exhibit A, that confirms acceptance of this Policy by Covered Individuals and assigns to the University all rights in any Intellectual Property in which the University asserts ownership (as described below). 1. Students - Students must sign the Participation Agreement prior to employment by the University in any research-related position. Such employment would include, for example, an arrangement whereby a student is funded as a research assistant under a government research grant or an industry-sponsored research agreement with the

39 39 University. Students may also be required to sign the Participation Agreement under other appropriate circumstances, as determined by the Vice Chancellor for Research. 2. Individuals Other Than Students - All Covered Individuals other than students must sign the Participation Agreement. The University will confirm that a valid Participation Agreement is on file before a Covered Individual receives any University-administered funds under a sponsored research grant or agreement. 1. Ownership of Intellectual Property Any Covered Individual who invents, creates, or discovers any Intellectual Property will own all rights to such Intellectual Property except as follows: 1. Use of University Resources - The University will own any Intellectual Property (other than Exempted Scholarly Works) that is made, discovered, or created by any Covered Individual who makes significant use of University resources (including Universityadministered funds or University-funded time, facilities, or equipment) in connection with the development of such Intellectual Property. If the Individual uses only library facilities and occasional use of office equipment to create the Intellectual Property, such use will not ordinarily be considered "significant use" of University resources. If a Covered Individual makes, creates or discovers Intellectual Property (other than Exempted Scholarly Works) that is the same as, directly related to, or substantially similar to a research project in which that faculty member is engaged at the University, then "significant use" of University resources will be presumed. As described below, the Covered Individual may rebut this presumption of University ownership through submission of documentary evidence which clearly establishes that the Intellectual Property was developed without significant use of University resources. 2. University-Commissioned Works - The University will own any Intellectual Property (including Exempted Scholarly Works) that is made, discovered, or created by a Covered Individual who is specifically hired or commissioned by the University for that purpose, unless otherwise provided by written agreement between such individual and the University. 3. Intellectual Property Subject to Contractual Obligations - Ownership of any Intellectual Property (including Exempted Scholarly Works) that is made, discovered, or created in the course of research funded by a sponsor pursuant to a grant or research agreement, or which is subject to a materials transfer agreement, confidential disclosure agreement or (UMD) other legal obligation affecting ownership, will be governed by the terms of such grant or agreement, as approved by the University, although the University will ordinarily claim ownership. 4. Student Works a. Generally - As with other Covered Individuals, students shall own any Intellectual Property that they make, discover, or create in the course of research (e.g., thesis or dissertation research) unless (i) the student received financial support from the University in the form of wages, salary, stipend, or grant funds for the research, (ii) the student made significant use of University resources (including University-administered funds or University-funded time, facilities, or equipment) in connection with the research, or (iii) the research was funded by a sponsor pursuant to a grant or sponsored research agreement or is subject to a materials transfer agreement, confidential

40 40 disclosure agreement, or other legal obligation that restricts ownership of Intellectual Property. b. Theses and Dissertations - All student theses and dissertations are considered Exempted Scholarly Works; therefore, the student will own copyright to the Scholarly Work (unless Sections III.B.2. or III.B.3. apply), subject to a royalty-free license to the University to reproduce and publish the Scholarly Work. As described below, students are allowed to publish their theses and dissertations unless they have agreed in writing to restrictions that preclude or delay publication. Under certain circumstances, as described in Section III.C.3. below, the University will relinquish its rights in Intellectual Property to the inventor or creator of that Intellectual Property at his or her request. C. Administrative Procedures - Inventions and Copyrightable Works A primary goal of the University is the discovery and free dissemination of knowledge for the benefit of the public. The University recognizes, however, that in certain instances the public will only benefit from knowledge that is protected under the patent or copyright laws, which provide an incentive for economic development of that knowledge. The University therefore requests that all Covered Individuals disclose Inventions and Copyrightable Works (other than Exempted Scholarly Works) promptly, in order to allow the University an opportunity to evaluate their commercial potential, and to preserve or enhance their value by filing a patent application or obtaining a copyright registration. The University has established the following procedures in order to accomplish the dual objectives of disseminating knowledge and maximizing the economic value of that knowledge. 1. Disclosure to the University - Disclosure forms should be submitted to the CVIP or the Vice Chancellor for Research. The Vice Chancellor for Research and the CVIP will exchange copies of all disclosure forms that each receives. The Vice Chancellor for Research will also make available to the campus Office of Grants and Contracts appropriate information to permit required disclosures to research sponsors (e.g., federal agencies). The CVIP will make available appropriate disclosure forms. The treatment of different categories of Intellectual Property is set forth below. a. Intellectual Property Developed with University Resources - All Covered Individuals are encouraged to disclose promptly all Inventions and Copyrightable Works (except Exempted Scholarly Works) that (i) are developed with significant use of University resources or (ii) are the same as, directly related to, or substantially similar to a research project in which that faculty member is engaged at the University (see Section III.B.1. above). Although the disclosure of such Inventions and Copyrightable Works is generally voluntary, if the Covered Individual intends to commercialize such Intellectual Property, disclosure is required reasonably before the Covered Individual takes any action to commercialize such Intellectual Property. Examples of commercial actions include, without limitation, seeking patent or copyright protection, commencing discussions with potential investors or licensees, or transferring the Intellectual Property to a third party. If a Copyrightable Work is an Exempted Scholarly Work, no disclosure is required under any circumstances. In other cases in which a Covered Individual desires treatment of a

41 41 Copyrightable Work as a Scholarly Work, the Covered Individual should submit to the CVIP or Vice Chancellor for Research, in addition to the disclosure form, a request for treatment of the work as a Scholarly Work and a brief explanation of why the work should be a Scholarly Work. In the case of an Invention or Copyrightable Work that the Covered Individual claims is not subject to University ownership because the Intellectual Property was developed without significant use of University resources, the Covered Individual should submit to the CVIP or Vice Chancellor for Research, in addition to the disclosure form, a request for confirmation of individual ownership together with documentary evidence which clearly establishes that fact. b. University-Commissioned Works - In the case of Inventions and Copyrightable Works (including Exempted Scholarly Works) that a Covered Individual is specifically hired or commissioned by the University to develop (see Section III.B.2. above), disclosure of the Intellectual Property is required unless otherwise provided by written agreement between such individual and the University. c. Intellectual Property Subject to Contractual Obligations (e.g., Sponsored Research Agreements) - In the case of Inventions and Copyrightable Works (including Exempted Scholarly Works) developed in the course of research funded by a sponsor pursuant to a grant or research agreement, or which is subject to a materials transfer agreement, confidential disclosure agreement or other legal obligation requiring disclosure, the disclosure of such Intellectual Property will be governed by the terms of such grant or agreement, as approved by the University, if such terms differ from this Policy. 2. Evaluation and Disposition of Disclosures - The Director and the Vice Chancellor for Research will review, evaluate, and make a disposition of all disclosure forms, and will promptly notify the Covered Individual of their disposition. The evaluation and disposition of a disclosure will be completed as soon as possible, but for Inventions (and computer software) ordinarily no later than ninety (90) days, and for Copyrightable Works (other than software) ordinarily no later than thirty (30) days after the CVIP or the Vice Chancellor for Research receives a complete and accurate disclosure form and any other information that the CVIP or the Vice Chancellor for Research requests in order to make an informed evaluation of an Invention or Copyrightable Work. Disclosure forms will be evaluated for one of more of the following dispositions, subject to the appeals process described in Section III.C.4. below: a. Scholarly Work - In the case of a Copyrightable Work that is claimed as a Scholarly Work (but is not an Exempted Scholarly Work), the Director and the Vice Chancellor for Research will decide whether that work is in fact a Scholarly Work. b. No Use of University Resources - In the case of an Invention or Copyrightable Work that the Covered Individual claims is not subject to University ownership because the Intellectual Property was developed without significant use of University resources, the Director and the Vice Chancellor for Research will decide whether there was in fact significant use of University resources. c. Evaluation of Commercial Potential: The Evaluation Committees - In the case of Intellectual Property that the Covered Individual discloses for possible commercialization by the University, the Director and the Vice Chancellor for Research

42 42 will determine its commercial potential. To assist in this determination, the Director and the Vice Chancellor for Research may consult with patent or copyright counsel and outside experts in particular fields. In addition to these resources, the Director and the Vice Chancellor for Research may seek the advice of various Evaluation Committees with expertise in various fields of research, which Committees the President shall have authority to establish at his or her discretion. Each Committee will be composed of faculty members with relevant expertise, appointed by the Chancellors in consultation with the Director and the Vice Chancellors for Research; a representative from the CVIP other than the Director; and a Committee Chair, selected by vote of the whole Committee. The Director may invite to any Committee meeting one or more individuals from outside the University with relevant industry experience to advise the Committee. In the case of Inventions or Copyrightable Works (including Exempted Scholarly Works) that arise in the course of research funded by a sponsor under a grant or research agreement, or which are subject to a materials transfer agreement, confidential disclosure agreement, or other legal obligation affecting evaluation of disclosures, the evaluation process will be governed by the terms of such grant or agreement, as approved by the University, if such terms differ from this Policy. In the unlikely event that the Director and the Vice Chancellor for Research disagree on the disposition of a disclosed Invention or Copyrightable Work, a final decision shall be made by the President. 3. Request for Relinquishment of Rights - Under certain circumstances, as described below, the University may relinquish its ownership rights in an Invention or Copyrightable Work to the inventor or creator of the Intellectual Property at his or her request. a. Intellectual Property Developed With University Resources - The University automatically waives its rights in Exempted Scholarly Works. In all other cases, the University will ordinarily waive its ownership rights in favor of the inventor or creator of an Invention or Copyrightable Work if the Covered Individual has made complete and accurate disclosure of such Intellectual Property in accordance with this Policy and the Director and Vice Chancellor for Research have determined that the Intellectual Property comes under one or more of the following categories (as described in detail above): Copyrightable Work that is a Scholarly Work Intellectual Property developed without significant use of University resources Intellectual Property that the University has decided not to commercialize b. University-Commissioned Works - The University will not ordinarily waive its ownership rights in any Intellectual Property (including Exempted Scholarly Works) that is developed by a Covered Individual who is specifically hired or commissioned by the University for that purpose, unless otherwise provided by written agreement between such individual and the University. c. Intellectual Property Subject to Contractual Obligations - In the case of Intellectual Property (including Exempted Scholarly Works) that is developed in the course of research funded by a sponsor pursuant to a grant or research agreement, or which is

43 43 subject to a materials transfer agreement, confidential disclosure agreement, or other legal obligation affecting ownership, the relinquishment of any University rights in the Intellectual Property will be governed by the terms of the relevant grant or agreement, as approved by the University, if such terms differ from this Policy. A Covered Individual may need a separate waiver or assignment of rights from the other party in order to acquire complete rights to the Intellectual Property. If certain Intellectual Property is available for relinquishment by the University (as set forth above), the inventor or creator of the Intellectual Property may request in writing that the Director grant a release or assignment of rights. The Director in consultation with the Vice Chancellor for Research will promptly respond to this request. The University will retain a royalty-free, non-exclusive license to use any such Inventions or Copyrightable Works for academic research and teaching. 4. Appeals - If a Covered Individual disagrees with a decision of the Director and the Vice Chancellor for Research under Section III.C.2., such individual may ask for reconsideration by the appropriate Evaluation Committee. The Committee shall review the matter and make its recommendation to the Director and the Vice Chancellor for Research who shall reconsider the matter. That decision may be appealed to the President, who shall review the written records and make a decision which shall be final. D. Administrative Procedures - Tangible Research Materials While potential commercial value should not inhibit the free exchange of Universityowned Tangible Research Materials for research purposes, the University nonetheless recognizes that such Materials may have significant commercial value. In addition, Tangible Research Materials received by Covered Individuals may be subject to contractual restrictions that severely limit the use and transfer of such Materials, to the detriment of University researchers. The University has therefore established the following procedures to allow the free exchange of Tangible Research Materials, while at the same time respecting the ownership rights of the University, protecting the rights of its researchers, and limiting the liability of the University and its researchers. 1. Transfer to Outside Researcher for Basic Research - If a Covered Individual desires to transfer Materials to an Outside Researcher for use in internal basic research, and not for the development or sale of commercial products, the Covered Individual must use the appropriate University form of Materials Transfer Agreement ("MTA"), which will be provided by the CVIP together with instructions for the use of each form. The various forms of MTA will establish rights and responsibilities regarding the Materials among the University and the Outside Researcher and his or her employer and will minimize future confusion and controversy regarding the use and transfer of the Materials and ownership of Inventions or Materials based on the supplied Materials. Faculty members (but not other Covered Individuals) are authorized to sign MTAs on behalf of the University provided that (i) the University-form MTA is not altered or revised in any manner and (ii) a signed original of the MTA is sent to the CVIP when the Materials are sent to the Outside Researcher. Alternatively, CVIP representatives are authorized to approve and sign MTAs, even with revisions. If Materials are developed by a Covered Individual in the course of sponsored research, or are otherwise subject to contractual restrictions (e.g., a materials transfer agreement

44 44 or confidential disclosure agreement), the transfer of such Materials to an Outside Researcher will be governed by the terms of the relevant agreement, if such terms differ from this Policy. These procedures also apply to students who leave the University and desire to bring with them Materials that they developed or discovered in the course of their work at the University. 2. Transfer for Commercial Use - Materials may not be transferred to any Outside Researcher for any use other than internal basic research unless the Outside Researcher has obtained a license from the University through the CVIP under the procedures set forth in this Policy. Materials with commercial uses should be disclosed to the CVIP or Vice Chancellor for Research in the same manner as Inventions and will be treated in the same manner as Inventions. 3. Receiving Materials from Outside Researchers - If a Covered Individual receives Materials from an Outside Researcher at another organization (non-profit or commercial), the other organization or researcher may impose serious use and transfer restrictions on the Materials and may claim an ownership interest in Inventions, Copyrightable Works, or Materials that arise in the course of research performed with such Materials. For this reason, only CVIP representatives are authorized to approve and sign agreements governing receipt of Materials from other organizations. Covered Individuals are encouraged to consult with the CVIP regarding the restrictions applicable to a particular Material from an Outside Researcher before planning to use that Material in their research. Covered Individuals should be aware that, in some instances, these restrictions may be so onerous that the CVIP will ordinarily not approve the agreement. The CVIP will make available a University-form MTA for receipt of Materials, although the organization supplying the Materials will usually require use of its own MTA. If Materials are received by a Covered Individual in the course of sponsored research, the transfer of such Materials will be governed by the terms of the applicable sponsored research agreement, if such terms differ from this Policy. If any MTA restrictions would apply to research performed by students, the affected students must agree to such restrictions in writing. E. Administrative Procedures - Confidential Treatment of Information While the academic tradition of free dissemination of knowledge for the public benefit is recognized by the University to be of paramount importance, it may be necessary or desirable, under some circumstances, to restrict disclosure of Confidential Information received from a sponsor company or to delay Public Disclosure of an Invention. The University has developed the following procedures to balance these competing interests. The University will ordinarily not agree to maintain University-generated research results as trade secrets. 1. Guidelines Regarding Public Disclosure of Inventions - Internal disclosure of an Invention to the CVIP or Vice Chancellor for Research will not interfere with the ability to patent the Invention. However, Public Disclosure of an Invention prior to filing for a patent application (even one day before) will preclude the availability of patent protection in most countries. This rule applies to any non-confidential written or oral disclosure that describes the Invention (e.g., at a scientific meeting, in a journal, or even

45 45 in an informal discussion with colleagues). Accordingly, the University strongly encourages Covered Individuals to disclose Inventions to the CVIP as soon as possible, and to delay Public Disclosure of the Invention until the evaluation process is completed and a patent application is filed. The CVIP and Vice Chancellor for Research will attempt to minimize delays in publication, but a delay of up to ninety days is often necessary for evaluation. The CVIP and Vice Chancellor for Research will make every effort to expedite the evaluation process when a Covered Individual indicates that there is a compelling need for rapid publication. During this interim period, an Invention may be safely disclosed outside of the University under the protection of a Confidential Disclosure Agreement ("CDA"), because disclosures made under an appropriate CDA are not considered Public Disclosures. The University therefore recommends that all Covered Individuals use the Universityform CDA whenever they disclose information relating to an Invention while the Invention is under evaluation by the University, and the University strongly recommends use of the University-form CDA and consultation with the CVIP if a Covered Individual wishes to disclose an Invention to an Outside Researcher associated with a company or other for-profit organization, or directly to such an organization. The CVIP will make available appropriate forms of CDA. Faculty members have authority to sign the University-form CDA on behalf of the University when they will disclose information (but will not receive information), provided they send a fully signed original of the CDA to the CVIP as soon as possible. Alternatively, CVIP representatives are authorized to approve and sign CDAs on behalf of the University. Covered Individuals should be aware that Public Disclosure of an Invention prior to completion of the evaluation process and filing of a patent application will adversely affect the commercial value of the Invention and therefore may decrease the likelihood that the University will proceed with commercialization of that Invention. In the case of an Invention or Copyrightable Work that arises in the course of sponsored research or a grant, or which is subject to a materials transfer agreement (MTA), confidential disclosure agreement, or other contractual restriction affecting Public Disclosure, any restrictions on Public Disclosure will be governed by the terms of the grant or agreement with the other party, as approved by the University. If such restrictions would prevent or delay the publication of a student thesis or dissertation, then he or she must agree to such restrictions in writing. 2. Receiving Confidential Information from Outside Researchers - If a Covered Individual receives Confidential Information from an Outside Researcher or organization (non-profit or commercial) in relation to research performed by the Covered Individual at the University, the other organization or researcher may impose serious non-disclosure and non-use obligations on the Confidential Information and may claim an ownership interest in Inventions, Copyrightable Works, or Materials that arise in the course of research performed with such Confidential Information. For this reason, only CVIP representatives are authorized to approve and sign CDAs from other researchers or organizations on behalf of the University. The CVIP will make available a Universityform CDA for receipt of Confidential Information, although the organization disclosing the Confidential Information will usually require use of its own form of CDA. When Confidential Information is received by a Covered Individual in the course of sponsored

46 46 research, the treatment of such Confidential Information will be governed by the terms of the applicable sponsored research agreement, if such terms differ from this Policy. If any CDA restrictions would apply to research performed by students, the affected students must agree to such restrictions in writing. F. Administrative Procedures - Sponsored Research with Commercial Organizations The Vice Chancellor for Research in consultation with the CVIP shall have responsibility for negotiating, executing, and administering funded research agreements between the University and commercial organizations, in accordance with the University policies on sponsored research. The Vice Chancellor for Research may delegate all or some of these responsibilities to the CVIP. CVIP approval is required for any terms of such agreements that affect rights to Intellectual Property (e.g., option rights, license rights, or assignment of ownership). If any restrictions in a funded research agreement (such as publication delays) would apply to research performed by students, the affected students must agree to such restrictions in writing. G. Commercialization of University-Owned Intellectual Property The CVIP in consultation with the Vice Chancellor for Research shall have responsibility for commercial development and administration of all University-owned Intellectual Property. This commercial development will ordinarily occur through licensing of Inventions, Copyrightable Works, or Materials to a company. If the CVIP is successful in its commercialization efforts, the inventor or creator will share in the economic rewards, as will the department and campus. 1. Distribution of Non-Equity Revenue Derived from Commercialization - Royalty income and other non-equity revenue derived from the licensing of University-owned Intellectual Property will be distributed at the end of each accounting period as follows: a. The University will be reimbursed for any out-of-pocket expenses incurred in obtaining and maintaining patent or copyright protection for a specific item of Intellectual Property, and in evaluating and marketing such Intellectual Property. b. The remaining net income will be distributed as follows: Fifteen percent (15%) to the CVIP to fund patents, CVIP operations, and research grants Thirty percent (30%) to the inventor or creator Fifteen percent (15%) to the department or program of the inventor or creator Forty percent (40%) to the campus of the inventor or creator In the case of multiple inventors or creators of commercialized Intellectual Property, their shares will be distributed as they unanimously agree or, in the absence of agreement, in equal portions. If multiple departments or programs are involved, their shares will be distributed in the same manner as the distributions to the inventors or creators within such departments or programs. 2. Acceptance of Equity - The University may accept an equity interest in a corporation, provided that before the CVIP agrees to accept equity, it must receive the approval of the Vice Chancellor for Research, the Vice President for Economic Development, and the University Treasurer. If the University receives equity in connection with the commercialization of Intellectual Property, such equity will be held on behalf of the University by the University of Massachusetts Foundation, Inc., and will be treated as follows:

47 47 a. Fifteen percent (15%) of the total equity will be held for the account of the CVIP until liquidation. b. Forty-five percent (45%) of the total equity will be held for the account of the department or program of the inventor or creator, or such other account as may be designated by the Chancellor of the campus, until liquidation. c. Forty percent (40%) will be held for the account of the campus until liquidation. This Policy does not provide for distribution of equity to the inventor or creator of the Intellectual Property because the University will not receive or hold equity on behalf of individuals. The inventor or creator, however, may receive equity directly from a commercial organization, subject to any restrictions contained in the University's Policy on Conflict of Interest Relating to Intellectual Property and Commercial Ventures. H. Enforcement The Director, the Vice Chancellor for Research, or the President may refer any matter to the appropriate University official for disciplinary or other appropriate action. I. Appeals; Interpretation of Policy; Exceptions The Director shall administer this Policy in regular consultation with the Vice Chancellors for Research and the President. The President, upon recommendation of the Vice President for Economic Development and in consultation with the General Counsel, may grant exceptions to the Policy in appropriate cases. The President shall have authority to overrule any decision of a Vice Chancellor or the Director. (Dartmouth Version, 2/3/97)

48 48 Exhibit A to Intellectual Property Policy University of Massachusetts Dartmouth Participation Agreement In consideration of the benefits that I receive as a result of my access to Universityadministered funds and University-funded time, facilities, and equipment, I agree as follows: 1. Acknowledgment. I acknowledge that I have read and understood the Intellectual Property Policy (the "Policy") of the University of Massachusetts (the "University"), a copy of which is attached to this Agreement, and I agree to abide by the terms of such Policy, as amended. I understand that capitalized terms used in this Agreement are defined terms that, if not defined in this Agreement, are defined in the Policy. 2. Disclosure. In accordance with Section III.C.1. of the Policy, I agree to make the following disclosures to the University Office of Commercial Ventures and Intellectual Property ("CVIP") or the Provost: 1. I am encouraged to disclose any Inventions, Copyrightable Works (except Exempted Scholarly Works), and commercially valuable Tangible Research Materials that (i) I develop with significant use of University resources or (ii) are the same as, directly related to, or substantially similar to a research project in which I am engaged at the University; however, if I intend to commercialize such Intellectual Property, disclosure is required reasonably before I take any action to commercialize such Intellectual Property. Examples of commercial actions include, without limitation, seeking patent or copyright protection, commencing discussions with potential investors or licensees, or transferring the Intellectual Property to a third party. 2. I am required to disclose any Inventions, Copyrightable Works (including Exempted Scholarly Works), and Tangible Research Materials that the University has specifically hired or commissioned me to develop, except as otherwise provided in a written agreement between me and the University; and 3. I am required to disclose any Inventions, Copyrightable Works (including Exempted Scholarly Works), and Tangible Research Materials that I develop in the course of research funded by a sponsor pursuant to a grant or research agreement that requires such disclosure, or which is subject to a materials transfer agreement, confidential disclosure agreement, or other legal obligation requiring such disclosure. I agree to make such disclosures promptly and in reasonable detail on the appropriate University Disclosure Form. In the case of Inventions that I intend to commercialize, I understand that I should make such disclosure reasonably prior to public disclosure of the Invention in order to provide the University with an opportunity to file a patent application. 3. Assignment of Rights. I hereby assign, transfer, and convey to the University all of my right, title, and interest in any Inventions, Copyrightable Works, and Tangible Research Materials for which the University asserts ownership under Section III.B. of the Policy. I understand that the University does not assert ownership of Exempted Scholarly Works unless such works are specifically commissioned by the University or are subject to a

49 49 contractual obligation that requires assignment. I further understand the University will ordinarily waive its rights in other Copyrightable Works that the University determines are Scholarly Works. At the request of the University, I agree to execute and deliver promptly a specific assignment to the University of my right, title, and interest to such Intellectual Property, including without limitation any proprietary rights arising from patent applications or copyright registration in the United States and foreign countries. I further agree to supply the University with all information and to execute all documents necessary to obtain and maintain patents, copyrights, or other forms of legal protection for such Intellectual Property. I hereby appoint the University as my attorney to execute and deliver such documents on my behalf in the event that I should fail or refuse to fulfill my obligations under this Section within a reasonable period of time. 4. Income-Sharing; Relinquishment. I understand that, in accordance with Section III.G.1. of the Policy, I will receive a portion of all royalty income and other non-equity revenue derived from the licensing of Intellectual Property that I assign to the University. I further understand that, in accordance with Section III.C.3. of the Policy, if the University decides not to commercialize such Intellectual Property, I will have an opportunity to regain title so that I may pursue commercialization of the Intellectual Property. 5. Administrative Procedures. I understand and agree to abide by the administrative procedures for the transfer of Tangible Research Materials and Confidential Information, as set forth in the Policy. 6. Certification by Principal Investigators. I agree to ensure that each person who is subject to the Policy who participates in research at the University under my supervision as Principal Investigator (excluding clerical and non-technical workers) has signed and delivered a copy of this Agreement in accordance with the Policy. I further agree to ensure that all students under my supervision as Principal Investigator have agreed in writing to any contractual restrictions (such as publication restrictions) that are applicable to their research. Signature: Printed Name: Department: Date: