TO: The Appointing Authorities of the Town of Chelmsford I, Paul Cohen am employed by the Town of Chelmsford as its Town

Manager. As part of my responsibilities, I sit on various boards and committees, specifically The Board of Trustees of the MIIA Health Benefits Trust I do not receive any compensation or pecuniary reward for the services that I provide as a member of such boards or committees, and neither I, nor any immediate family member has any direct or indirect financial interest in any of theses entities. In accordance with MGL Chapter 268A, section 19, I am requesting an advance written determination by the appointing boards and committees disclosed above is not so substantial as to be deemed likely to affect the integrity of the services which the Town of Chelmsford may expect from me. By signing below, you confirm that as the appointing authorities of the Town of Chelmsford, youve been advised as the nature and circumstances of my involvement with the boards and committees, agree that my interest is not so substantial as to be deemed likely to affect the integrity of the services which the municipality may expect from me and grant me the exemption permitted a municipal employee under MGL Chapter 268A, section 19.

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Date: _____________________________