Fillable OGE Form 450 Nov 2019 OGE Form 450

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OGE Form 450 Nov 2019 OGE Form 450

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  • 34 check-boxes
  • 98 other fields

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OGE Form 450, 5 CFR Part 2634, Subpart I
U.S. Office of Government Ethics (Nov 2019)
Expires 11/30/21
Form Approved
OMB No. 3209-0006
What is the
Reporting Period?
New Entrants:
Part I – Report assets as of the date of filing but report sources of earned income,
honoraria, and other non-investment income for the preceding 12 months.
Part II – Report liabilities as of the date of filing.
Part III – Report positions for the preceding 12 months.
Part IV – Report agreements and arrangements as of the date of filing.
Annual Filers: Report the required information for the preceding calendar year
(January 1 – December 31).
If you have any questions about how to complete this form, please contact your ethics
What if I Have
Questions?
official or go to the Office of Government Ethics web site at www.oge.gov and select
2*( Form 450&RQILGHQWLDO)LQDQFLDO'LVFORVXUH5HSRUW under Forms Library.
PENALTIES
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 authority. Knowing and willful falsification of information
required to be reported may also subject you to criminal prosecution.
Privacy Act Statement
Title I of the Ethics in Government Act of 1978 (5 U.S.C. app. 101), Executive Order 12674 (as modified by Executive Order 12731), and 5
CFR Part 2634, Subpart I, of the Office of Government Ethics (OGE) regulations require the reporting of this information. Failure to
provide the requested information may result in separation or disciplinary action. The primary use of the information on this form is for
review by Government officials of your agency, to determine compliance with applicable Federal conflict of interest laws and regulations.
Additional disclosures may be made pursuant to the routine uses set forth in OGE/GOVT-2: (1) to a Federal, State, or local law
enforcement agency if the disclosing agency becomes aware of a violation or potential violation of law or regulation; (2) to a source when
necessary to obtain information relevant to a conflict of interest investigation or decision; (3) to the National Archives and Records
Administration in records management inspections; (4) to the Office of Management and Budget during legislative coordination on private
relief legislation; (5) when the disclosing agency determines that the records are arguably relevant to a proceeding before a court, grand
jury, or administrative or adjudicative body, or when the adjudicator determines the records to be relevant to the proceeding; (6) to
reviewing officials in a new office, department or agency when an employee transfers or is detailed from one covered position to another;
(7) to a Member of Congress or a congressional office in response to an inquiry made on behalf of and at the request of an individual who
is the subject of the record; (8) to contractors and other non-Government employees working for the Federal Government to accomplish a
function related to this OGE Government-wide system of records; (9) to appropriate agencies, entities and persons when there has been a
suspected or confirmed breach of the system of records, the agency maintaining the records has determined that there is a risk of harm to
individuals, the agency, the Federal Government, or national security, and the disclosure is reasonably necessary to assist in connection
with the agency's efforts to respond to the suspected or confirmed breach or to prevent, minimize, or remedy such harm; and (10) to
another Federal agency or Federal entity, when the agency maintaining the record determines that information from this system of records
is reasonably necessary to assist the recipient agency or entity in responding to a suspected or confirmed breach or in preventing,
minimizing, or remedying the risk of harm to individuals, the recipient agency or entity, the Federal Government, or national security.
Note: When an agency is requested to furnish such records to OGE, such a disclosure is to be considered as made to those officers and
employees of the agency which co-maintains the records who have a need for the records in the performance of their official duties in
accordance with the Ethics in Government Act and other pertinent authority conferred on OGE, pursuant to the provisions of the Privacy
Act at 5 U.S.C. 552a(b)(1). This confidential report will not be disclosed to any requesting person unless authorized by law. See also the
OGE/GOVT-2 Executive Branch Confidential Financial Disclosure Reports Privacy Act system of records.
Public Burden Information
It is estimated that completing this form, including reviewing the instructions and gathering the data needed, takes an average of three
hours. No private citizen is required to respond to a collection of information unless it displays a currently valid OMB control number as
printed in the top right-hand corner of the first page of this form. Send comments regarding the burden estimate or any other aspect of this
collection of information, including suggestions for reducing this burden, to: Program Counsel, U.S. Office of Government Ethics, Suite
500, 1201 New York Avenue, NW, Washington, DC 20005-3917. Do not send your completed OGE Form 450 to this address.
CONFIDENTIAL FINANCIAL DISCLOSURE REPORT
Executive Branch
Why Must I File?
The duties and responsibilities of your position require you to file the Confidential
Financial Disclosure Report to avoid involvement in a real or apparent conflict of
interest. The purpose of this report is to assist employees and their agencies in
avoiding conflicts between official duties and private financial interests or affiliations.
The information you provide will only be used for legitimate purposes, and will not be
disclosed to any requesting person unless authorized by law. (See the Privacy Act
Statement at the bottom of this page.) Please ensure that the information you provide
is complete and accurate.
When Must I File?
New Entrants: The report is due within 30 days of your assuming a position
designated for filing, unless your agency requests the report earlier or your agency
grants you a filing extension.
Annual Filers: The report is due no later than February 15, unless your agency
grants you a filing extension.
Use arrow keys to read all text. Tab to complete form.
Date Received by Agency
Form Approved
OMB No. 3209-0006
Page Number
CONFIDENTIAL FINANCIAL DISCLOSURE REPORT
Executive Branch
Employee’s Name (Print last, first, middle initial) E-mail Address
Position/Title Grade
Agency Branch/Unit and Address
Work Phone
If New Entrant, Date of Appointment to Position
(mm/dd/yy)
Check box if Special
Government Employee (SGE)
An SGE is an executive branch officer or employee who is retained, designated,
appointed, or
employed to perform temporary duties either on a full-time or intermittent basis, with or without
compensation, for a period not to exceed 130 days during any consecutive 365-day period.
If an SGE, Mailing Address (Number, Street, City, State, ZIP Code)
Step 1: Read the instructions for Parts I through V on the following pages.
Step 2: For each statement below, check Yes or No to describe your situation.
I. I have reportable assets or sources of income for myself, my spouse, or my dependent
children.
Yes No
II. I have reportable liabilities (debts) for myself, my spouse, or my dependent children.
Yes No
III. I have reportable outside positions for myself.
Yes No
IV. I have reportable agreements or arrangements for myself.
Yes No
NOTE: Statement V is for annual filers only. It does not apply to new entrants and SGEs.
V. I have reportable gifts or travel reimbursements for myself, my spouse, or my dependent
children.
Yes No
Step 3: If you selected Yes for any statement, you must describe the reportable interests that you have in the corresponding
Part (I, II, III, IV, or V) of the form.
Step 4: Sign and date the form.
Step 5: Submit the completed form to your ethics office.
I certify that the statements I have made on this form and all attached statements are true, complete, and correct to the
best of my knowledge.
Signature of Employee Date (mm/dd/yy)
FOR REVIEWERS’ USE ONLY:
On the basis of information contained in this report, I conclude that the filer is in compliance with applicable laws and
regulations, except as noted in the “comments” box below.
Signature and Title of Supervisor/Other Intermediate Reviewer (if required by the agency) Date (mm/dd/yy)
E-mail Address Phone Number
Signature and Title of Agency’s Final Reviewing Official Date (mm/dd/yy)
Comments of Reviewing Officials
(Check box if continued on additional page )
OGE Form 450, 5 CFR Part 2634, Subpart I
U.S. Office of Government Ethics (Nov 2019)
Expires 11/30/21
Reporting Status
New Entrant Annual
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Form Approved
OMB No. 3209-0006
Employee’s Name (Print last, first, middle initial) Page Number
Part I: Assets and Income
Report for Yourself, Spouse, and Dependent Child: Do Not Report:
• Assets held for investment or the production of income that
ended the reporting period with a value greater than $1,000.
In addition, annual filers must report assets from which more
than $1,000 in income was received during the reporting
period. Reportable assets include, but are not limited to:
- Assets such as stocks, bonds, annuities, trust holdings,
partnership interests, life insurance, investment real
estate, or a privately-held trade or business
- Sector mutual funds: those funds invested in a particular
industry, business, or location, such as ABC Electronics
Fund or XYZ Canada Fund (report the full name of the
fund, not just the family fund name)
- Holdings of retirement plans, such as 401(k)s or IRAs,
investment life insurance, or variable annuities (report
each holding unless listed in the Do Not Report section)
- Defined benefit pension plans provided by a former
employer (include the name of the employer)
• Federal Government retirement benefits
• Thrift Savings Plan
• Certificates of deposit, savings or checking
accounts
• Term life insurance
• Money market mutual funds and money market
accounts
• Your personal residence, unless you rent it out
• U.S. Government Treasury bonds, bills, notes, and
savings bonds
• Diversified mutual funds, such as ABC Equity
Value Fund or XYZ Large Capital Fund
• Diversified funds within an employee benefit plan
• Money owed to you, your spouse, or dependent
child by a spouse, parent, sibling, or child
Also Report: Do Not Report:
• For yourself: (1) all sources of salary, fees, commissions, and
other earned income greater than $1,000, (2) honoraria
greater than $1,000, and (3) other non-investment income
such as scholarships, prizes, and gambling income greater
than $1,000
• For your spouse: (1) all sources of salary, fees, commissions,
and other earned income greater than $1,000, and
(2) honoraria greater than $1,000
• Dependent child’s earned income
• Veterans’ benefits
• Federal Government salary
• Social Security benefits
Important Definitions
Diversified Mutual Fund – A mutual fund that does not have a stated policy of concentrating its investments in one industry,
business, or single country other than the United States.
Sector Mutual Fund – A mutual fund that concentrates its investments in an industry, business, single country other than
the United States, or bonds of a single state within the United States.
Dependent Child – A son, daughter, stepson or stepdaughter who is either unmarried and under age 21 and living in the
filer’s house, or considered dependent under the U.S. tax code.
Reportable Information – Go to the last page to see examples of how to report assets and income.
Specific stock, bond, sector mutual fund, type/location of real estate, etc. (Indicate the full name of each
specific asset or investment. You may add the ticker symbol to the full name.)
Name of Employer or Business; Source of Fees, Commissions, or Honoraria (Include brief description.)
You may distinguish any entry for a family member by preceding it with S for spouse, DC for dependent child,
or J for jointly held.
No longer
held
1
2
3
4
5
OGE Form 450, 5 CFR Part 2634, Subpart I
U.S. Office of Government Ethics (Nov 2019)
Expires 11/30/21
Diversified Fund within an Employee Benefit Plan – An employee benefit plan fund that has a written policy of varying
investments without concentration in one industry, business, or single country other than the United States.
Employee’s Name (Print last, first, middle initial) Page Number
Part I: Assets and Income
Continuation Page
Specific stock, bond, sector mutual fund, type/location of real estate, etc. (Indicate the full name of each
specific asset or investment. You may add the ticker symbol to the full name.)
Name of Employer or Business; Source of Fees, Commissions, or Honoraria (Include brief description.)
You may distinguish any entry for a family member by preceding it with S for spouse, DC for dependent child,
or J for jointly held.
No longer
held
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
OGE Form 450, 5 CFR Part 2634, Subpart I
U.S. Office of Government Ethics (Nov 2019)
Expires 11/30/21
Form Approved
OMB No. 3209-0006
Add Page
Employee’s Name (Prin
t last, first, middle initial) Page Number
Part II: Liabilities
Report for Yourself, Spouse, and Dependent Do Not Report:
Child:
Reportable Information – Go to the last page to see examples of how to report liabilities.
Name of creditor (include city and state
where creditor is located)
Type of liability (personal loan, margin account, etc.)
1
2
Part III: Outside Positions
Report for Yourself: Do Not Report:
• • Any position with a
- Religious entity
- Social entity
- Fraternal entity
- Political entity
• Any position held by your spouse
or dependent child
• Any position that you hold as part
of your official duties
Reportable Information – Go to the last page to see examples of how to report outside positions.
Organization
(include city and state where organization is located)
Type of organization Position No longer
held
1
2
3
4
5
6
Form Approved
OMB No. 3209-0006
OGE Form 450, 5 CFR Part 2634, Subpart I
U.S. Office of Government Ethics (Nov 2019)
Expires 11/30/21
All positions outside the U.S. Government held at any time during the
reporting period, whether or not you were compensated and whether or not
you currently hold that position. Positions include an officer, director,
employee, trustee, general partner, proprietor, representative, executor, or
consultant of any of the following:
- Corporation, partnership, trust, or other business entity
- Non-profit or volunteer organization
- Educational institution
- State or Local Government
• If you are a new entrant filer, liabilities that
exceeded $10,000 at the end of the
reporting period
• If you are an annual filer, liabilities that
exceeded $10,000 during the reporting
period
• Any liability, such as a mortgage, a student loan, or a credit card
account, from a financial institution or business entity granted on
terms made available to the general public
• Loans secured by automobiles, household furniture, or appliances,
unless the loan exceeds the purchase price of the item it secures
• Liabilities that you owe to your spouse or to the parent, sibling, or
child of you, your spouse, or your dependent child
Add Page
Form Approved
OMB No. 3209-0006
Employee’s Name (Print last, first, middle initial) Page Number
Part IV: Agreements or Arrangements
Reportable Information – Go to the last page to see examples of how to report agreements and arrangements.
Entity with which you have an agreement
or arrangement (include city and state
where entity is located)
Terms of Agreement or Arrangement
1
2
3
4
Part V: Gifts and Travel Reimbursements
Fill out this part only if you are filing an Annual Report. If you are a new entrant or an SGE, skip this part.
Report for Yourself, Spouse, and Dependent Child: Do Not Report:
•
Any gifts or travel reimbursements (items such as lodging,
transportation, and food) totaling more than $390* from any one
source during the reporting period; include where you traveled,
the purpose, and date(s) of the trip for travel gifts and
reimbursements
*If you received more than one gift from one source:
1.
Determine the value of each item you received from that source
2.
Ignore each item valued at $156 or less
3.
Add the value of those items valued at more than $156; if the total
is more than $390, then you must list those items on this form
Reportable Information – Go to the last page to see examples of how to report gifts and travel reimbursements.
Source
Description
1
2
3
OGE Form 450, 5 CFR Part 2634, Subpart I
U.S. Office of Government Ethics (Nov 2019)
Expires 11/30/21
Report Your Agreements or Arrangements for: Do Not Report:
• Continuing participation in an employee pension or benefit plan
maintained by a current or former employer
• A leave of absence
• Future employment, including date you accepted employment offer
• Continuation of payment by a current or former employer
(including severance payments)
• Any agreement or arrangement related to your
employment by the Federal Government
• Spouse’s and dependent child’s agreements or
arrangements
• Continuing participation in a defined contribution
plan, such as a 401(k) plan, to which an
employer is no longer making contributions
• Anything received from relatives, the U.S.
Government, D.C., state, or local governments
• Bequests and other forms of inheritance
• Gifts and travel reimbursements given to your
agency in connection with your official travel
• Gifts of hospitality (food, lodging,
entertainment) at the donor’s residence or
personal premises
• Anything received by your spouse or
dependent child totally independent of their
relationship to you
Add Page
Part I: Assets and Income
Part II: Liabilities
Part V: Gifts and Travel Reimbursements
Form Approved
OMB No. 3209-0006
EXAMPLES
Specific stock, bond, sector mutual fund, type/location of real estate, etc. (Indicate the full name of
each specific asset or investment. You may add the ticker symbol to the full name.)
Name of Employer or Business; Source of Fees, Commissions, or Honoraria (Include brief
description.)
You may distinguish any entry for a family member by preceding it with S for spouse, DC for dependent
child, or J for jointly held.
No longer
held
OGC Communications (OGC) (Example of a stock with a ticker symbol)
OGE Energy (Example of sold stock that produced more than $1,000 in income)
(S) OGE Energy bond (Example of a corporate bond held by a spouse)
ABC Healthcare Fund (Example of a sector fund held in a 401(k) plan)
Residential real estate, Anchorage, AK (Example of investment real estate)
Bryggadune University – salary (Example of earned income from a former employer)
(S) Express Medical Clinic – salary (Example of a spouse's earned income from a current employer)
Association of Accountants – honorarium (Example of a single honorarium from the listed source)
Name of creditor (city and state)
Type of liability (personal loan, margin account, etc.)
John Jones (Denver, CO)
Personal loan from a friend
ANW Investment Company (San Francisco,
CA)
Margin account
Part III: Outside Positions
Organization
(city and state)
Type of organization Position No longer
held
Bryggadune University
(Memphis, TN)
Educational institution Professor
ISK Family Trust
(Boynton Beach, FL)
Family Trust Trustee
Scenic Rivers Association
(Nashville, TN)
Non-profit environmental
organization
Member, Board of
Directors
Part IV: Agreements or Arrangements
Entity with which you have an agreement
or arrangement (include city and state
where entity is located)
Terms of Agreement or Arrangement
Dee, Jones & Smith
(San Diego, CA)
I will continue to participate in this defined benefit plan. (Example of
continuing participation in a defined benefit plan with a former employer)
Hartford & Brown
(San Diego, CA)
Employment agreement with Hartford & Brown. Starting work as attorney
in July 2019. Entered into agreement in October 2018. (Example of an
agreement for future employment)
Source De
scription
Dee, Jones & Smith
Leather briefcase
(Example of a gift totaling more than $390 from one source)
CGH Culinary Institute
Airline ticket, hotel room, and meals incident to culinary seminar in Tokyo,
Japan from May 1-5, 2018 (Example of a travel reimbursement)
OGE Form 450, 5 CFR Part 2634, Subpart I
U.S. Office of Government Ethics (Nov 2019)
Expires 11/30/21
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OGE Form 450 Nov 2019 OGE Form 450

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Completed 18 March 2020

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