State Rep. Mindy Domb 2018 SFI

Statement of Financial Interests for 2017
CONTACT INFORMATION
Last Name: First Name and Middle initial:
Domb Mindy
Work Phone Number: Other Phone:
(413) 549-3968 Ext : 107 Redacted
Work Email: Other Email:
domb@amherstsurvival.org Redacted
Primary Residence Address:
Redacted
Contact mailling address
Redacted
You indicated that you did have a spouse residing in your household during 2017.
You indicated that you had no dependent child(ren) residing in your household at any time during 2017.
Candidacy and Public Service
1. If you are a candidate for public office, please indicate the public office you are seeking.
Office
Representative in General Court
2. Identify the position you now hold, or have held, which requires you to file a Statement of Financial Interests and
provide the required information for that position. If you held more than one public position which requires you to
file, identify each position.
Filer reported none.
Original Page 1 of 13
3. Other than the position(s) identified in Question 2, identify every public position you held, and every public
agency to which you provided services, at any time during 2017, whether compensated or not, and whether full- or
part-time.
4. Identify every public position your spouse and/or any dependent child(ren) residing in your household held, and
every public agency to which your spouse and/or any dependent child(ren) residing in your household provided
services, at any time during 2017, whether compensated or not, and whether full- or part-time.
Private Employment and Leaves of Absence
5. Identify every Business for which you worked as an employee, manager, consultant, or independent contractor at
any time during 2017, whether compensated or not, and whether full- or part-time, and provide the required
information for each.
Business Name Self-employed Address Position Income
Amherst N/A PO Box 9629, 138 Manager $60,001 to

Survival Sunderland Road, North 100,000
Center Amherst, MA, 01059, US
6. Identify any Business from which you were on a leave of absence at any time during 2017, and provide its address.
7. Identify every Business for which your spouse and/or any dependent child(ren) residing in your household worked
as an employee, manager, consultant, or independent contractor at any time during 2017, whether compensated or
not, and whether full- or part-time, and provide the required information for each.
Business Name Self-employed Address Position
Baystate Medical N/A 140 High Street, Employee

Practices Springfield, MA, 01199, US
Business Ownership and Transfers
8. Identify each Business of which you were, in whole or in part, an owner, partner, or proprietor, or in which you
owned more than 1% of any class of the outstanding stock or similar ownership interest, at any time during 2017,
and provide the required information for each.
9. Identify each Business of which your spouse and/or any dependent child(ren) residing in your household was, in
whole or in part, an owner, partner, or proprietor, or in which your spouse and/or any dependent child(ren) residing in
your household owned more than 1% of any class of the outstanding stock or similar ownership interest, at any time
during 2017, and provide the required information for each.
10. Identify any stock or similar ownership interest in a Business which you transferred to your spouse and/or any
dependent child(ren) residing in your household during 2017, and provide the required information for each.
Service as an Officer, Director, or Trustee
11. Identify any Business in which you served as an officer, director, or trustee, at any time during 2017, whether
compensated or not, and whether full- or part-time, and provide the required information for each.
12. Identify any Business in which your spouse and/or any dependent child(ren) residing in your household served as
an officer, director, or trustee, at any time during 2017, whether compensated or not, and whether full- or part-time,
NOTE: If the Filer answered “YES” to a Question in the following section, one or more columns in the Table for that
Question may be blank in the following situations: If the Filer indicated that the name of the person and/or the trust was a
family member’s name or address, the Filer was not required to provide that name. If the Filer indicated that an address
was a family member’s address, the Filer was not required to provide that address.
Real Estate
13. Identify all Real Estate in Massachusetts which you owned directly or through a Business as of December 31,
2017, and which had an assessed value greater than $1,000, and provide the required information for each Real
Estate holding.
Ownership Legend:
Filer = F
Spouse/Child(ren) = S/C
Trust = T
Property Address Owner Transferred? Transferor Name Transferor Address Assessed Value
Redacted F, S/C No $100,001 or

more
14. Other than the Real Estate identified in Question 13, identify all Real Estate in Massachusetts which your spouse
and/or any dependent child(ren) residing in your household owned directly or through a Business as of December 31,
2017, and which had an assessed value greater than $1,000, and provide the required information for each Real
Estate holding.
15. Identify any Trust of which you were a beneficiary and which owned Real Estate in Massachusetts as of
December 31, 2017, with an assessed value greater than $1,000, and provide the required information for each such
Trust and Real Estate holding.
Beneficiary Legend:
Filer = F
Trust = T
16. Other than the Real Estate identified in Question 15, identify any Trust of which your spouse and/or any
dependent child(ren) residing in your household was a beneficiary and which owned Real Estate in Massachusetts as
of December 31, 2017, with an assessed value greater than $1,000, and provide the required information for each
such Trust and Real Estate holding.
17. Identify any Real Estate in Massachusetts with an assessed value greater than $1,000, that was transferred to
another person or entity by you, or by a Trust of which you were a beneficiary, at any time during 2017, and provide
the required information for each Real Estate holding.
Ownership Legend:
Filer = F
Trust = T
18. Other than the Real Estate identified in Question 17, identify any Real Estate in Massachusetts with an assessed
value greater than $1,000, that was transferred to another person or entity by your spouse and/or any dependent
child(ren) residing in your household, or by a Trust of which your spouse and/or any dependent child(ren) residing in
your household was a beneficiary, at any time during 2017, and provide the required information for each piece of
Real Estate transferred.
Ownership Legend:
Filer = F
Trust = T
19. Identify any Real Estate in Massachusetts with an assessed value greater than $1,000, on which, as of
December 31, 2017, you, or a Trust of which you were a beneficiary, had a lien, attachment, or mortgage receivable,
Ownership Legend:
Filer = F
Trust = T
20. Other than the Real Estate identified in Question 19, identify any Real Estate in Massachusetts with an assessed
value greater than $1,000, on which, as of December 31, 2017, your spouse and/or any dependent child(ren) residing
in your household, or a Trust of which your spouse and/or any dependent child(ren) residing in your household, had a
lien, attachment, or mortgage receivable, and provide the required information for each.
Ownership Legend:
Filer = F
Trust = T
Financial Investments
21. Identify every bond or other security issued by the Commonwealth of Massachusetts or its political subdivisions,
agencies, and authorities, which you owned directly or through a Business, as of December 31, 2017, and which had
a fair market value as of that date greater than $1,000, and provide the required information for each such
investment.
Ownership Legend:
Filer = F
Trust = T
22. Other than the bonds or other securities identified in Question 21, identify every bond or other security issued by
the Commonwealth of Massachusetts or its political subdivisions, agencies, and authorities, which your spouse
and/or any dependent child(ren) residing in your household owned directly or through a Business, as of December
31, 2017, and which had a fair market value as of that date greater than $1,000, and provide the required information
for each such investment.
agencies, and authorities, which was owned as of December 31, 2017, by a Trust of which you were a beneficiary,
whether directly or through a Business, and which had a fair market value as of that date greater than $1,000, and
provide the required information for each such investment.
Beneficiary Legend:
Filer = F
Trust = T
agencies, and authorities, which was owned as of December 31, 2017, by a Trust of which your spouse and/or any
dependent child(ren) residing in your household was a beneficiary, whether directly or through a Business, and which
had a fair market value as of that date greater than $1,000, and provide the required information for each such
investment.
25. Identify every Financial Investment that you owned directly or through a Business as of December 31, 2017, and
which had a fair market value as of that date greater than $1,000, and provide the required information for each.
Ownership Legend:
Filer = F
Trust = T
26. Other than the Financial Investments identified in Question 25, identify every Financial Investment that your
spouse and/or any dependent child(ren) residing in your household owned directly or through a Business as of
December 31, 2017, and which had a fair market value as of that date greater than $1,000, and provide the required
information for each. For any Financial Investment not included on the drop-down list of publicly traded stock, you
must provide the issuer's principal place of business or state of incorporation as well as its address.
27. Identify every Financial Investment that was owned as of December 31, 2017, by a Trust of which you were a
beneficiary, and which had a fair market value as of that date greater than $1,000, and provide the required
information for each. For any Financial Investment not included on the drop-down list of publicly traded stock, you
must provide the issuer's principal place of business or state of incorporation as well as its address.
Beneficiary Legend:
Filer = F
Trust = T
28. Other than the Financial Investments identified in Question 27, identify every Financial Investment that was
owned as of December 31, 2017, by a Trust of which your spouse and/or any dependent child(ren) residing in your
household was a beneficiary, and which had a fair market value as of that date greater than $1,000, and provide the
required information for each. For any Financial Investment not included on the drop-down list of publicly traded
stock, you must provide the issuer's principal place of business or state of incorporation as well as its address.
Debts and Mortgages
29. Identify all mortgages, including home equity and reverse mortgage loans, on your Primary Residence, on which
more than $1,000 was owed as of December 31, 2017, where the creditor (person who loaned you the money) is
NOT, by blood or marriage, your parent, grandparent, great grandparent, child, grandchild, great grandchild, aunt,
uncle, sister, brother, niece, nephew, or the spouse of any such relative, and provide the required information for
each.
Creditor Name Creditor Address Mortgage Term Interest Rate (%) Termination Year
Florence Bank 385 College Street, 10 years 2.75 2028

Amherst, MA, 01002, US
30. Did you have a mortgage, including a home equity or reverse mortgage loan, on any property OTHER than your
Primary Residence, on which more than $1,000 was owed as of December 31, 2017, which you were obligated to
pay and where the creditor (person who loaned you the money) is NOT, by blood or marriage, your parent,
grandparent, great grandparent, child, grandchild, great grandchild, aunt, uncle, sister, brother, niece, nephew, or
the spouse of any such relative?
Obligor Legend:
Filer = F
Trust = T
31. Identify all mortgages, including home equity and reverse mortgage loans, OTHER than any mortgage on your
Primary Residence or any mortgage identified in response to Question 30, on which more than $1,000 was owed as
of December 31, 2017, and which your spouse and/or any dependent child(ren) residing in your household were
obligated to pay and where the creditor (person who loaned the money to your spouse and/or dependent child(ren)
residing in your household) is NOT, by blood or marriage, your parent, grandparent, great grandparent, child,
grandchild, great grandchild, aunt, uncle, sister, brother, niece, nephew, or the spouse of any such relative, and
provide the required information for each.
32. Identify all non-mortgage debts of more than $1,000 that you owed as of December 31, 2017, IF the person to
whom you owed the debt is NOT, by blood or marriage, your parent, grandparent, great grandparent, child,
grandchild, great grandchild, aunt, uncle, sister, brother, niece, nephew, or the spouse of any such relative, and
33. Identify all non-mortgage debts of more than $1,000 that your spouse and/or any dependent child(ren) residing in
your household owed as of December 31, 2017, IF the person to whom your spouse and/or any dependent child(ren)
residing in your household owed the debt is NOT, by blood or marriage, your parent, grandparent, great grandparent,
child, grandchild, great grandchild, aunt, uncle, sister, brother, niece, nephew, or the spouse of any such relative, and
34. Identify non-mortgage debts of more than $1,000 which you owed and which were forgiven at any time during
2017, EXCLUDING debts forgiven by a person who is, by blood or marriage, your parent, grandparent, great
grandparent, child, grandchild, great grandchild, aunt, uncle, sister, brother, niece, nephew, or the spouse of any
such relative, and provide the required information for each.
35. Identify non-mortgage debts of more than $1,000 that were owed by your spouse and/or any dependent child(ren)
residing in your household and were forgiven at any time during 2017, EXCLUDING debts forgiven by a person who
is, by blood or marriage, your parent, grandparent, great grandparent, child, grandchild, great grandchild, aunt, uncle,
sister, brother, niece, nephew, or the spouse of any such relative, and provide the required information for each.
Reimbursments, Gifts, and Honoraria
36. Identify any Reimbursements for expenses in excess of $100 provided to you at any time during 2017 by any
legislative agent or executive agent (lobbyist).
36.a Identify any Reimbursements for expenses in excess of $100, other than those identified in response to
Question 36, you received at any time during 2017 from any person having a direct interest in legislation, legislative
action, or a matter before a governmental body.
37. Identify any Reimbursements for expenses in excess of $100 provided to your spouse and/or any dependent
child(ren) residing in your household at any time during 2017 by any legislative agent or executive agent (lobbyist).
37.a Identify any Reimbursements for expenses in excess of $100, other than those identified in response to
Question 37, provided to your spouse and/or dependent child(ren) residing in your household at any time during 2017
by any person having a direct interest in legislation, legislative action, or a matter before a governmental body.
38. Identify any Gifts and/or Honoraria worth more than $100 provided to you at any time during 2017 by any person
having a direct interest in legislation, legislative action, or a matter before a governmental body.
39. Identify any Gifts and/or Honoraria worth more than $100 provided to your spouse and/or any dependent
child(ren) residing in your household at any time during 2017 by any person having a direct interest in legislation,
legislative action, or a matter before a governmental body.
Blind Trusts
40. Did you, your spouse and/or any dependent child(ren) residing in your household during 2017, own anything that
you have not reported on this Statement of Financial Interests because it was held in a Blind Trust during 2017?
CERTIFICATION
I, Mindy Domb, certify under the pains and penalties of perjury that:
I made a diligent effort to obtain the required information concerning myself and my spouse and/or any dependent child(ren); and
The information provided on this form is true and complete, to the best of my knowledge.
Submitted: 04/24/2018
Did your spouse and/or any dependent child(ren) residing in your household decline to disclose information which is necessary to complete this
form fully and accurately?
The following are the specific Question(s) which I decline to answer in whole or in part because I assert that the information is privileged by law:
Please explain the basis of your claim of privilege:
IMPORTANT:
1. No DESIGNATED PUBLIC EMPLOYEE shall be allowed to continue in their duties or to receive compensation from public funds unless
they have filed a Statement of Financial Interests with the State Ethics Commission.
2. The State Ethics Commission does not accept a faxed or emailed copy of a Statement of Financial Interests for filing.
3. If you were required to amend your Statement of Financial Interests last year, we encourage you to carefully review your 2017
filing before submitting.

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State Rep. Mindy Domb 2018 SFI

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Statement of Financial Interests for 2017

Last Name: First Name and Middle initial:

Work Phone Number: Other Phone:

(413) 549-3968 Ext : 107 Redacted

Work Email: Other Email:

Primary Residence Address:

Contact mailling address

Candidacy and Public Service

Representative in General Court

Filer reported none.

Filer reported none.

Filer reported none.

Private Employment and Leaves of Absence

Business Name Self-employed Address Position Income

Amherst N/A PO Box 9629, 138 Manager $60,001 to

Filer reported none.

Business Name Self-employed Address Position

Baystate Medical N/A 140 High Street, Employee

Filer reported none.

Filer reported none.

Filer reported none.

Service as an Officer, Director, or Trustee

Filer reported none.

Filer reported none.

Redacted F, S/C No $100,001 or

Filer reported none.

Filer reported none.

Filer reported none.

Filer reported none.

Filer reported none.

Filer reported none.

Filer reported none.

Filer reported none.

Filer reported none.

Filer reported none.

Filer reported none.

Filer reported none.

Filer reported none.

Filer reported none.

Filer reported none.

Debts and Mortgages

Florence Bank 385 College Street, 10 years 2.75 2028

Filer reported none.

Filer reported none.

Filer reported none.

Filer reported none.

Filer reported none.

Filer reported none.

Filer reported none.

Filer reported none.

Filer reported none.

Filer reported none.

Filer reported none.

Filer reported none.

Filer reported none.

form fully and accurately?

Please explain the basis of your claim of privilege:

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