Donor Certification Form

U.S. Department of the Interior OMB Control No. 1090-XXXX Donor Certification Form Expires: / /

Thank you for your interest in making a donation to the Department of the Interior or one of its bureaus (Bureau of Land Management, Bureau of Reclamation, Bureau of Indian Affairs, Minerals Management Service, National Park Service, Office of Surface Mining, U.S. Fish and Wildlife Service, and U.S. Geological Survey, or other Departmental bureau). It is Interior’s policy to ensure that in accepting donations, the Department maintains its integrity and impartiality, and the confidence of the public. The following certification helps the Department and you, the potential donor, to identify areas of concern that might be raised by a donation. An affirmative answer to any of the statements below does not mean a donation will be declined, but may initiate further review.

I am executing this Donor Certification Form as _____ an individual or _____ on behalf of the following organization or person:_____________________________________________________________________.

To the best of my knowledge and belief, I certify that:

1. I am / am not involved in litigation or other controversy with the Department or its bureaus.

2. I am / am not seeking or otherwise engaged in any type of financial or business relationship with the Department, for example, a contract, permit, lease, grant, or cooperative agreement.

3. I have / have not been debarred, suspended, proposed for debarment, excluded or disqualified under the nonprocurement common rule, or otherwise declared ineligible from doing business with any Federal government agency.

4. This donation is / is not expected to be involved with marketing or advertising.

5. I am / am not seeking to attach condition(s) to this donation.

6. This donation is / is not part of a series of donations to the Department or its bureaus.

For any affirmative answers above, please attach explanations. Please also identify any other circumstances not addressed in the above questions that may affect the Department’s decision to accept your donation.

With my signature I hereby certify the above statements are accurate and attest that I am not aware of other issues regarding this donation that may be of concern to the Department. I also certify that this donation is not intended to influence any decision or action by the Department or to obtain any special treatment from the Department. I understand that the Department’s acceptance of this donation does not constitute endorsement by the Department of me or my products or services.

______________________________ ______________________________ ____________________

Signature Printed Name Date

_______________________________________________________________ ____________________

Organization E-mail address

______________________________ __________ __________ ____________________

City State Zip Daytime or Work Phone

Information collected via this form will be handled in accordance with the requirements of the Privacy Act and the Freedom of Information Act to attempt to ensure the greatest protection of personal privacy. Please see Notices pertaining to this Form on Page 2.

NOTICES

PRINCIPAL PURPOSE: This information is collected to support the Department’s policy that in accepting donations, the Department maintains its integrity and impartiality, and the confidence of the public by providing the donor the opportunity to certify certain basic information related to the gift.

EFFECT OF NOT PROVIDING THIS FORM: Submission of the form is completely voluntary, but not providing it may delay consideration of your proposed gift to the Department as it will make it more difficult for the Department to determine the context of the gift. Submitting the form does not entitle the respondent to any benefit.

AUTHORITY: The authority for collecting this information may be found at 9 Stat. at L. 395, Ch. 108, at 18 U.S.C. § 201, and at 374 Departmental Manual Chapter 6.

PAPERWORK REDUCTION ACT NOTICE: The Paperwork Reduction Act of 1995 requires us to inform you that: the Department of the Interior, or one of its bureaus or offices, collects the information requested on this form pursuant to a proposal of a donor to proffer a gift to the Department or one of its bureaus or offices valued at least $25,000. The Department, bureau or office will evaluate the certification regarding your proposed gift to support its policy of ensuring integrity and impartiality in the fulfillment of its missions. This Information Collection has been approved by the Office of Management and Budget (OMB), and the currently valid OMB Control Number and Expiration Date appears on the upper right corner of Page 1 of the Form. No Federal agency may request or sponsor, and you are not required to respond to, a request for information which does not contain a currently valid OMB Control Number.

BURDEN HOURS STATEMENT: The public burden for this form is estimated at 20 minutes per response including the time for reviewing instructions, gathering and maintaining data, and completing and reviewing the form. Direct comments regarding the burden estimate or any other aspect of this form to: U.S. Department of the Interior, Office of the Secretary, Bureau Information Collection Clearance Officer, 1951 Constitution Avenue, N.W., (MS 116 SIB), Washington, D.C. 20240. Note – comments, names and addresses of commentators are available for public review during regular business hours. If you wish us to withhold this information, you must state this prominently at the beginning of your comment. We will honor your request to the extent allowable by law.