FORM OSM 23 (8/89) UNITED STATES DEPARTMENT OF THE INTERIOR
Office of Surface Mining Reclamation and Enforcement
State Employee Statement of Employment and Financial Interest
Approved by OMB
CN 1029-0067
Expires: 8/31/2020
1. Name (Last, First, Initial)
3. Date of Appointment (in present position)
5. Duty Station (Office location)
7. Calendar Year (previous)
General Instructions. Report all interests held during the previous calendar year (indicate which ones are no longer held), use attachments as necessary.
In the event that any of the required information is not known to you, but is known to another person (e.g., trustee, accountant, relative), request that
the other person submit the information on your behalf. Provide the name and address of the other person, and include the date you requested the
information to be supplied. Briefly explain the situation and the information requested. Codes: (E) for Employee, (J) for Joint ownership with
spouse, minor child or other relatives, (S) for Spouse, (C) for minor child or (R) for other Relatives who are full-time residents in your immediate
household.
Part I. Employment and Securities. List the names of business entities, non-profit organizations, educational and other institutions in which you,
your spouse, minor child or other relatives who are full-time residents of your immediate household have a financial interest, including but not limited
to: (1) an interest as an employee, officer, owner, director, trustee, partner or consultant; (2) a continuing financial interest through a pension or
retirement plan, individual retirement account, shared income, or other arrangement as a result of any current or prior employment; (3) any financial
interest through the ownership of stock, bonds, securities or other arrangement including trusts. You may exclude: (1) positions with charitable,
religious, fraternal, political organizations or any similar organization and those solely of an honorary nature; (2) holdings in widely held diversified
mutual funds, investment clubs or regulated investment companies not specializing in underground and surface coal mining operations; (3)
employment, pension or retirement plans with the U.S. or State Governments; and (4) retirement plans with a guaranteed income. A guaranteed income
is one which is unlikely to be changed as a result of actions taken by the State regulatory authority.
NONE
Code J, S,
C or R
Name and Address of Organization Description of Interest
(e.g., employment, stock)
Nature of Employment and Financial
Interest (e.g., salary, dividends)
Part II. REAL PROPERTY. List property in which you,
your spouse, minor child or other relatives who are full-time residents of your
immediate household have an interest. Exclude your personal residence. Personal residence means any real property used exclusively as a private
dwelling.
NONE
Code J, S,
C or R
Nature of Interests (e.g., ownership,
lease, royalty, mineral rights)
Description of Interest
(e.g., employment, stock)
Location of Interest
(county and state)
Part III. CREDITORS. List debts owed to business entities and non-profit organizations to whom you, your spouse, minor child or other relatives
who are full-time residents of your immediate household are indebted. Exclude debts owed to financial institutions (e.g., banks, credit unions), credit
cards, and those for ordinary household and living expenses.
NONE
Code J, S,
C or R
Nature of Interests (e.g., ownership,
lease, royalty, mineral rights)
Description of Interest
(e.g., employment, stock)
Location of Interest
(county and state)
Part IV. EMPLOYEE CERTIFICATION. To the best of my knowledge, none of the employment and financial interests listed represents an interest
in an underground or surface coal mining operation except as follows:
NONE
Code J, S,
C or R
Nature of Interests (e.g., employment, mineral rights, stock, undeveloped land)
I certify that the statements I have made are true, correct, and complete to the best of my knowledge.
Signature of Employee Date
