Financial Disclosure Certification

Public members of the Administrative Conference of the United States are deemed to be special government employees within the meaning of 18 U.S.C. § 202(a) and, therefore, are subject to confidential financial disclosure requirements of the Ethics in Government Act, 5 U.S.C app. § 107, and U.S. Office of Government Ethics (OGE) regulations.

This form is a substitute for OGE Standard Form 450 that Administrative Conference public members otherwise would be required to file. It was approved by the Director of the Office of Government Ethics following a determination by the Conference Chairman, pursuant to 5 C.F.R § 2634.905(a), that greater disclosure by public members is not required because the duties of a member make remote the possibility that a real or apparent conflict of interest will occur.

As required by the Ethics in Government Act, 5 U.S.C. app. § 107(a); Executive Order 12674, § 201(d); and OGE regulations, 5 C.F.R. §2634.901(d), this report will be held in strict confidence.

Please click on the form below for online submission. Direct all questions to Shawne McGibbon, General Counsel, at smcgibbon@acus.gov or 202.480.2088.

Part I: GENERAL INFORMATION

Your Name (required)

E-Mail Address (required)

Administrative Conference committee (required)

Employer (required)

Occupation or Position Title (required)

Part II: OUTSIDE POSITIONS
Report any outside positions, whether or not compensated, which you held outside the U.S. Government in the last year but only if such positions involved responsibilities that relate in some way to the subject matter of any item on the agenda of the upcoming ACUS plenary session or of a meeting of an ACUS committee of which you are a member. You need not report any positions of your spouse or dependent children.

Note: Positions include but are not limited to those of an employee, officer, director, trustee, general partner, proprietor, representative, or consultant of any corporation, firm, partnership, or other business, enterprise or any non-profit organization or educational institution. Exclude positions with religious, social, fraternal, or political entities or those solely of an honorary nature.

 None.

1. (if applicable)

2. (if applicable)

3. (if applicable)

Part III: AGREEMENTS AND ARRANGEMENTS
Report below any current agreements or arrangements for future employment, leaves of absence, payment by a former employer (including severance payments), or continuing participation in an employee benefit plan, but only if such agreements or arrangements relate in some way to the subject matter of any item on the agenda of the upcoming ACUS plenary session or of a meeting of an ACUS committee of which you are a member. You need not report any agreements or arrangements of your spouse or dependent children.

 None.

1. (if applicable)

2. (if applicable)

3. (if applicable)

Part IV: ASSETS, INCOME AND LIABILITIES
Identify for you, your spouse, and dependent children: (1) each asset held for investment or the production of income that exceeds $1,000 in value (excluding accounts in banks, savings and loans and similar depository institutions and U.S. Government obligations, such as U.S savings bonds and government-issued securities); (2) each asset or source of income which generated over $200 in income in the previous year; and (3) any liabilities over $10,000 (excluding a residential mortgage, consumer loans, and liabilities owed to immediate family members), but only if such assets, income, and liabilities relate in some way to the subject matter of any item on the agenda of the upcoming ACUS plenary session or of a meeting of an ACUS committee of which you are a member. Report only the identity and nature of income; do not include the amount or value of assets, income, or liabilities.

Note: This part is intended to require no greater disclosure than is required by OGE Standard Form 450 which would require disclosure of assets, income and liabilities regardless of their relevance to ACUS matters. However, because OGE’s regulations on disclosure of assets, income, and liabilities contain additional exclusions from reporting, members are advised to consult with the ACUS General Counsel/Designated Agency Ethics Official if they have questions about the reporting of assets, income, and liabilities described above.

 None.

1. (if applicable)

2. (if applicable)

3. (if applicable)

I certify that the statements I have made on this form are true, complete, and correct to best of my knowledge.

(Typed Signature of Public Member)

(Date)

(Signature of Designated Agency Ethics Official)

(Date)

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