Form OSM 23 OSM 23 State Employee Statement of Employment and Financial Int

FORM OSM 23 (8/89) UNITED STATES DEPARTMENT OF THE INTERIOR Appoved by OMB

Office of Surface Mining Reclamation and Enforcement CN 1029-0067

State Employee Statement of Employment and Financial Interest Expires: 8/31/08

1. Name (Last, First, Initial)	2. Title of Position
3. Date of Appointment (in present position)	4. Organizational Unit
5. Duty Station (Office location)	6. Telephone No.	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 any of the required information is not known to you, but is known to another person (e.g., trustee, accountant, relative), you should request that other person to submit the information on your behalf. Give 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.

P art 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: (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; (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 residents 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)

P art 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)

P art 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

Part V. REVIEWERS CERTIFICATION. Review completed and prohibited interests, if any, have been resolved. Reviewer’s comments, if any, show the basis for the certification:

Signature of Reviewer

Date

PRIVACY AND PAPERWORK REDUCTION ACT NOTICES

Section 517(g) of Public Law 95-87, the Surface Mining Control and Reclamation Act, and 30 CFR 705, constitute the authority for collecting the personal data on this statement of employment and financial interests. This data must be furnished. Knowing failure to file or report information required may subject you to disciplinary action by your employing agency or other appropriate authority. Knowing failure to file or report information required may also subject you to criminal prosecution leading to a fine of not more than $2,500 or imprisonment for not more than one year or both.

The information gathered from the statement will be used to determine whether there are any direct or indirect financial interests in violation of Section 517(g) of Public Law 95-87.

Maintenance of the statement by the State regulatory authority is subject to State law. Pursuant to 30 CFR 705 the statement may be inspected by or provided to representatives of the U.S. Department of the Interior.

If the statement is provided to the U.S. Department of the Interior, the statement will be subject to the requirements of Federal law, including the Privacy Act of 1974, 5 U.S.C. 552a. The U.S. Department of the Interior may make routine disclosures: (1) from the records of an individual in response to an inquiry from a Congressional office made at the request of that individual; (2) to the U.S. Department of Justice when related to litigation or anticipated litigation involving the records or the subject matter of the records; and (3) to appropriate State and Federal law enforcement agencies.

Public reporting burden for this form is estimated to average 20 minutes per response, including time for reviewing instructions, gathering and maintaining data, and completing and reviewing the form. You are not required to respond to this collection of information unless it displays a currently valid OMB control number. Direct comments regarding the burden estimate or any other aspect of this form to the Information Collection Clearance Officer, Office of Surface Mining Reclamation and Enforcement, Room 210 SIB, 1951 Constitution Ave., NW, Washington, D.C., 20240.