Financial Disclosure Certification
Public Member Confidential Employment And Financial Disclosure Report
OMB Control Number 3002-0003, exp. May 31, 2014
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 firstname.lastname@example.org or 202.480.2088.
Privacy Act Statement
Title I of the Ethics in Government Act of 1978 (5 U.S.C. App.), Executive Order 12674, and 5 CFR Part 2634, Subpart I, of the Office of Government Ethics regulations require the reporting of this information. The primary use of the information on this form is for review by the Administrative Conference, to determine compliance with applicable Federal conflict of interest laws and regulations. Additional disclosures of the information on this report may be made: (1) to a Federal, State, or local law enforcement agency if the agency becomes aware of a violation of the law or regulation; (2) to a court or party in a court or federal administrative proceeding if the Government is a party or in order to comply with a subpoena; (3) to a source when necessary to obtain information relevant to a conflict of interest investigation or decision; (4) to the National Archives and Records Administration or the General Services Administration in records management and inspections; (5) to the Office of Management and Budget during legislative coordination on private relief legislation; and (6) in response to a request for discovery or for the appearance of a witness in a judicial or administrative proceeding, if the information is relevant to the subject matter. This confidential report will not be disclosed to any requesting person unless authorized by law.
Falsification of information or failure to file or report information required to be reported may subject you to disciplinary action by your employing agency or other appropriate authority. Knowing and willful falsification of information required to be reported may also subject you to criminal prosecution.
Paperwork Reduction Act Statement
The average burden for each response to this information collection is estimated to be less than 15 minutes. Any comments concerning the accuracy of this burden estimate and any suggestions for reducing this burden may be directed to the Office of the Chairman of the Administrative Conference.
An agency may not conduct or sponsor and a person is not required to respond to a collection of information unless it displays a current valid OMB control number.