Fillable Cd Request Format Request For A Certificate of Divestiture

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Cd Request Format Request For A Certificate of Divestiture

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The Cd Request Format Request For A Certificate of Divestiture form is 6 pages long and contains:

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  • 21 check-boxes
  • 35 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Office of Government Ethics

BROWSE OFFICE OF GOVERNMENT ETHICS (DC) FORMS

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Clear Form
REQUEST FOR A CERTIFICATE OF DIVESTITURE
(must be completed by the agency, not by the requesting employee)
Requesting employee’s name and position title: Employing agency and component:
Agency point of contact:
Telephone number and email address for agency
point of contact:
Signature of DAEO or ADAEO: Date signed:
For complete instructions on requesting a Certificate of Divestiture (CD), please review 5 C.F.R. part
2634, subpart J.
1.
Provide the requested information about the
property being divested and the owner(s) of that
property (see sample table to the right):
(a)
description of the property: include the name of the property
being divested;
(b)
quantity or percentage owned: quantity may be represented
by the number of shares of stock, units owned,
or percentage of the partnership owned;
(c)
owner(s) of the property: provide the full name of the
owner(s) of the property; and
(d)
relationship to the employee: indicate whether each property
owner is one of the following: (i) a government employee; (ii) a
spouse, a minor child or a dependent child of the government
employee; or (iii) a trustee of a trust for the benefit of the
government employee, the spouse, minor or dependent child of
the government employee.
Please provide the requested information in an Excel spreadsheet or Word document if a CD is being requested
for more than six holdings. Please do not submit financial statements.
(a) Description of the property
(b) Quantity or
percentage
owned
(c) Owner(s) of
the property
(d) Relationship to
the employee
(a) Description
of the property
(b) Quantity
or
percentage
owned
(c) Owner(s)
of the
property
(d) Relationship
to the employee
McDonald’s
Corp.
57 shares
John A.
Jones
self
General Electric
Co.
251 shares
John A.
Jones (joint)
Mary B. Jones
self
spouse
Play Toys, LP
12.24%
interest
Mary B.
Jones
spouse
Merck & Co.,
Inc.
33 shares
William C.
Smith
trustee
Coca-Cola, Co.
55 shares
John A.
Jones (as
custodian)
Robert D.
Jones
self
dependent child
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(a) Description of the property
(b) Quantity or
percentage
owned
(c) Owner(s) of
the property
(d) Relationship to
the employee
2.
Provide a brief description of the employee’s position or provide a citation to a statute or regulation that sets
forth the duties of the position. (If additional space is needed, please use the continuation page
at the end of
the format.)
3.
Provide a detailed explanation of the basis for your conclusion that divestiture is reasonably necessary to
comply with Federal ethics rules. (If additional space is needed, please use the continuation page at the end
of the format.)
4. Provide the date that the requirement to divest first applied or the date the employee first agreed that the eligible
person would divest the property in order to comply with conflict of interest requirements. (If additional space is
needed, please use the continuation page at the end of the format.)
5. Please address all items below (If additional space is needed, please use the continuation page at the
end of the format.):
a.
Has the employee been informed of their obligation to recuse from particular matters in which the
employee would have a disqualifying financial interest arising from the property described in the employee's
request for a Certificate of Divestiture?
Yes No (if no, please explain using the continuation page
)
b.
Was the property acquired prior to appointment?
Yes No (if no, please explain using the continuation page)
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c.
Will divestiture of the property incur capital gains rather than ordinary income?
Yes No (if no, please explain using the continuation page)
d.
Has the ethics office confirmed that none of the employee’s other financial interests are “similar or related”
to the property being divested (i.e., will divestiture resolve the entire conflict)?
Yes No (if no or if additional explanation is needed, p
lease explain using the continuation page)
e.
Has the ethics office confirmed that the property being divested is not held in an account that can be rolled
into permissible property in a tax-deferred account without incurring capital gains (e.g., IRA, 401(k), etc.)?
Yes No (i
f no, please explain using the continuation page)
f.
Is the request within the divestiture deadline?
Yes No (if no, please explain using the continuation page)
6.
Are there any other factors that are not addressed above that weigh against issuing a certificate of divestiture
(e.g., is the ethics office aware that the employee may be leaving the Government soon, or is under investigation or
subject to a disciplinary action related to the conflict of interest requirements)? If yes, provide a detailed statement
identifying the factors that weigh against issuing a certificate of divestiture on a continuation page.
Yes
No
7.
Please confirm that you are submitting a completed CD package, including:
a.
A written request from the employee that includes an unconditional statement that the eligible person
holding the property (i.e., the employee, spouse, and/or relevant trustee) has agreed to divest the property.
Yes
No
b.
A copy of the employee’s most recent financial disclosure report including any required subsequent Periodic
Transaction Reports, or a list of the equivalent information if the employee does not file a financial disclosure
report.
Yes
No
c.
A copy of the trust document if any of the property is held in a trust.
N/A
Yes
No
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8.
Please provide any additional information that you would like OGE to consider when processing the
request. (If additional space is needed, please use the continuation page a
t the end of the format.)
Please send the completed CD package to CD@oge.gov or to the following address: Director, U.S.
Office of Government Ethics, 1201 New York Avenue, NW, Suite 500, Washington, DC
20005-3917.
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REQUEST FOR A CERTIFICATE OF DIVESTITURE
Continuation Page
Before each response, please indicate the question for which you are providing additional information.
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REQUEST FOR A CERTIFICATE OF DIVESTITURE
Continuation Page
Before each response, please indicate the question for which you are providing additional information.
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Cd Request Format Request For A Certificate of Divestiture

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Completed 1 November 2019

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