DD Form x586 Post Government Employment Advice Opinion Request

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POST-GOVERNMENT EMPLOYMENT ADVICE OPINION REQUEST

The public reporting burden for this collection of information is estimated to average 90 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering
and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information,
including suggestions for reducing the burden, to the Department of Defense, Washington Headquarters Services, Executive Services Directorate, Information Management Division, 1155 Defense
Pentagon, Washington, DC 20301-1155 (XXXX-XXXX). Respondent should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with
a collection of information if it does not display a currently valid OMB control number.

PLEASE DO NOT RETURN YOUR FORM TO THE ABOVE ORGANIZATION.

PRIVACY ACT STATEMENT
AUTHORITY: 41 U.S.C. 423; 10 U.S.C. 1701 note; 5 C.F.R. 2635.107, Joint Ethics Regulation.
PRINCIPAL PURPOSE(S): To enable ethics counselors to render ethics advice to military and civilian employees leaving Government service.

D R A F T

ROUTINE USE(S): None.

DISCLOSURE: Voluntary; however, failure to fully disclose information requested may result in receipt of incomplete advice or inability to provide
written advice. This may result in a delay in being hired by a Department of Defense contractor or receipt of compensation from such contractor.
Failure to comply may also result in the imposition of administrative penalties in accordance with section 27e of the Office of Federal Procurement
Policy Act (41 U.S.C. 423(e)).

SECTION I - CONTACT INFORMATION
1. DOD AGENCY YOU WORKED OR ARE WORKING
FOR (e.g., US Army, US Navy, etc.)

2.a. FIRST NAME

3. ADDRESS
a. STREET 1

b. MIDDLE
INITIAL

c. LAST NAME

b. STREET 2

c. CITY

d. STATE

4. TELEPHONE NUMBER (Include Area Code)

5. E-MAIL ADDRESS

6. HOW DO YOU WANT TO RECEIVE YOUR OPINION (X one)

e. ZIP/POSTAL CODE

BY E-MAIL

f. COUNTRY

BY POSTAL MAIL

SECTION II - SERVICE INFORMATION
7. EMPLOYEE STATUS AT TIME OF SEPARATION OR TERMINAL/TRANSITION LEAVE
8. DOD ORGANIZATION

MILITARY

CIVILIAN

9. DOD SUPERVISOR'S NAME

10. REASON FOR SEPARATION
RETIREMENT

RESIGNATION

OTHER (Specify)

11. SEPARATION/RETIREMENT DATE (MM/DD/YYYY)

12. TERMINAL/TRANSITION LEAVE DATE (MM/DD/YYYY)

13. DO YOU PLAN TO WORK WHILE ON TERMINAL/TRANSITION
LEAVE?
NO
YES

14. FOR CIVILIAN EMPLOYEES: DID YOU RETIRE FROM THE
U.S. ARMED FORCES?
NO
YES

SECTION III - PRIOR ETHICS INFORMATION
15. PRIOR ETHICS ADVICE
a. HAVE YOU RECEIVED ANY ETHICS ADVICE OR OPINION FROM ANOTHER GOVERNMENT ETHICS COUNSELOR CONCERNING YOUR
PROSPECTIVE EMPLOYMENT?
NO PRIOR ADVICE RECEIVED
YES, PRIOR ADVICE RECEIVED (Complete b.)
b. (1) ETHICS COUNSELOR'S NAME

(2) OFFICE

(3) TELEPHONE NUMBER

16. FINANCIAL DISCLOSURE
a. IN THE LAST 2 YEARS, HAVE YOU FILED A FINANCIAL DISCLOSURE REPORT?
NO

YES, OGE FORM 450

YES, SF 278 (If you file a SF 278, you must file a termination report no later than 30 days after
separation.)

b. IF YES, POSITIONS FOR WHICH YOU FILED

DD FORM X586, 20100322 DRAFT

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SECTION III - PRIOR ETHICS INFORMATION (Continued)
17. CONFLICT OF INTEREST
a. IN THE LAST 2 YEARS, HAVE YOU TAKEN ANY ACTION TO RESOLVE A POTENTIAL CONFLICT OF INTEREST, INCLUDING ISSUING
A WRITTEN DISQUALIFICATION, CHANGING JOBS, HAD YOUR DUTIES CHANGED, OR TAKEN ANY OTHER ACTION TO RESOLVE A
POTENTIAL CONFLICT OF INTEREST?
NO
YES
b. IF YES, PROVIDE DETAILS:

D R A F T
18. ETHICS PLEDGE
a. HAVE YOU SIGNED THE ETHICS PLEDGE?

NO

YES

b. IF YES, HAVE YOU RECEIVED A WAIVER OF THE RESTRICTIONS THAT APPLY UPON LEAVING THE GOVERNMENT?
NO

YES

c. IF YES, EXPLAIN THE EXTENT OF THE WAIVER:

d. IF NO, DO YOU ANTICIPATE WORK AS A LOBBYIST?
NO

YES

19. LICENSED ATTORNEY: PLEASE INDICATE IF YOU ARE A LICENSED ATTORNEY, EVEN IF YOU ARE NOT EMPLOYED AS AN
ATTORNEY BY DOD.
NO , I AM NOT A LICENSED ATTORNEY

YES, I AM A LICENSED ATTORNEY

SECTION IV - DOD POSITION INFORMATION
20. POSITIONS HELD AND MAJOR DUTIES: IN WHAT AGENCIES OR ORGANIZATIONS HAVE YOU SERVED DURING YOUR LAST 2 YEARS
OF DEPARTMENT OF DEFENSE SERVICE? (Provide dates (month and year). For each position, describe your job or briefly describe your major duties
during the last 2 years, focusing on duties relating to defense contracts, any aspect of the acquisition process, such as requirements development, acting as
program manager, deputy program manager or contracting officer, or otherwise involved in the contracting process. Identify names of projects, program, contractors
and subcontractors.)

a. CURRENT/MOST RECENT POSITION
(1) ORGANIZATION OR AGENCY

(2) JOB TITLE

(3) DESCRIPTION

b. PRIOR POSITION 1
(1) ORGANIZATION OR AGENCY

(2) JOB TITLE

(3) DESCRIPTION

c. PRIOR POSITION 2
(1) ORGANIZATION OR AGENCY

(2) JOB TITLE

(3) DESCRIPTION

DD FORM X586, 20100322 DRAFT

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SECTION IV - DOD POSITION INFORMATION (Continued)
20. POSITIONS HELD AND MAJOR DUTIES (Continued)
d. PRIOR POSITION 3
(1) ORGANIZATION OR AGENCY

(2) JOB TITLE

(3) DESCRIPTION

e. PRIOR POSITION 4
(1) ORGANIZATION OR AGENCY

(2) JOB TITLE

(3) DESCRIPTION

D R A F T
21. WITHIN THE LAST TWO YEARS, HAVE YOU SERVED IN ANY OF THE FOLLOWING POSITIONS OR PERSONALLY TAKEN ONE OF THE
FOLLOWING ACTIONS REGARDING AN ACQUISITION OR CONTRACT IN EXCESS OF $10 MILLION?
a. CONTRACTING OFFICER OR SOURCE SELECTION AUTHORITY?
NO

YES

b. A MEMBER OF A SOURCE SELECTION EVALUATION BOARD, OR A CHIEF OF A FINANCIAL OR TECHNICAL EVALUATION TEAM?
NO

YES (If Yes, summarize your duties/responsibilities:)

c. PROGRAM MANAGER, DEPUTY PROGRAM MANAGER, OR ADMINISTRATIVE CONTRACTING OFFICER?
NO

YES (If Yes, summarize your duties/responsibilities:)

d. APPROVAL OF A CONTRACT, SUBCONTRACT, MODIFICATION,
TASK ORDER OR DELIVERY ORDER, OR PAYMENT OF A
CONTRACT CLAIM?
NO

YES

e. ESTABLISHING OVERHEAD
OR OTHER RATES?
NO

YES

f. APPROVAL OF A CONTRACT
PAYMENT?
NO

YES

g. IF YOU ANSWERED "YES" TO ANY OFTHESE QUESTIONS, IDENTIFY THE CONTRACT(S) IN WHICH YOU PERFORMED THAT FUNCTION
(List contract number(s), title(s) and date(s) of last action)

22.a. DO YOU HOLD A POSITION IN THE EXECUTIVE SERVICE,
SENIOR EXECUTIVE SERVICE OR A GENERAL OR FLAG
POSITION (Grade O7 and above - not frocked)?
NO
YES

DD FORM X586, 20100322 DRAFT

b. DID YOU PARTICIPATE IN AN ACQUISITION WITH A VALUE IN
EXCESS OF $10 MILLION?
NO

YES
Page 3 of 4 Pages

SECTION V - PROSPECTIVE EMPLOYER INFORMATION
23. POSITIONS SOUGHT: WITH WHOM ARE YOU SEEKING EMPLOYMENT?

24. ACTIONS TAKEN: WHAT ACTIONS HAVE YOU TAKEN CONCERNING YOUR FUTURE EMPLOYMENT?

25. FUTURE JOB TITLE
a. JOB TITLE

b. JOB DESCRIPTION (Include information on how this may relate to your Government duties.)

D R A F T
26. START DATE: WHEN DO YOU PLAN TO START YOUR NEW EMPLOYMENT? (MM/DD/YYYY)
27. ADDITIONAL COMMENTS

I certify that the information provided on this form is true and accurate to the best of my knowledge.
28. PRINTED FULL NAME
29. SIGNATURE

DD FORM X586, 20100322 DRAFT

30. DATE SIGNED

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Page 4 of 4 Pages

INSTRUCTIONS FOR COMPLETING DD FORM X586
Please answer all questions as appropriate. Then print your full name,
sign and date the form.
SECTION I - CONTACT INFORMATION.

17. Conflict of Interest. X one. If within the last 2 years, you have
taken any action to resolve a potential conflict of interest, including
issuing a written disqualification, changing jobs, had your duties
changed, or taken any other action to resolve a potential conflict of
interest, mark Yes. Provide a summary of the actions you took to
resolve the conflict of interest. If you have not taken any action to
resolve a potential conflict of interest, mark No.

D R A F T

1. Please provide the Department of Defense Agency of your last
assignment. (Example: US Army, US Air Force, Defense Intelligence
Agency.) Do not abbreviate.
2. Enter your first name, middle initial and last name.
3. Enter your complete home address, including country if this
address is outside the United States.
4. Provide a current telephone number to include the area code or
country code if appropriate. Provide an alternate current telephone
number to include the area code or country code if appropriate in the
remarks section if you are in transition.

18. Ethics Pledge. X one. Mark Yes if you signed an Ethics
Pledge. Mark No if you did not sign an Ethics Pledge.
If Yes, did you receive any waivers of the restrictions that may
apply to you when departing DoD service? X one.
If you signed an Ethics Pledge and received a waiver concerning
employment restrictions upon leaving DoD service, provide a
summary of the waiver notification.
19. Licensed Attorney. X one. Self explanatory.
SECTION IV - DoD POSITION INFORMATION.

5. Provide a current valid e-mail address. Provide an alternate current
e-mail address in the remarks section if you are in transition.
6. Contact preference. Mark (X) e-mail or postal mail to indicate your
preference on how to provide the written opinion to you.
SECTION II - SERVICE INFORMATION.
7. Employee Status. X Military or Civilian.
8. Provide the name of the last organization you were assigned to as
a member of DoD. Do not abbreviate.
9. Provide the name of your immediate supervisor of your last position
in DoD.
10. Reason for Separation. X one. Mark Retirement if you retired or
are retiring from DoD. Mark Resignation if you resigned or are
resigning from DoD. Mark Other if neither retirement nor resignation
applies.
11. Separation/Retirement Date. Enter date in MM/DD/YYYY format.
12. Terminal/Transition Leave Date. Enter date in MM/DD/YYYY
format.

20. Positions Held and Major Duties. Self explanatory.
21. Duties and Actions if Involved in a Contract in Excess of $10
Million.
a. X one. Self explanatory.
b. X one. If Yes, provide a summary of your duties and
responsibilities if you served as a member of a Source Selection
Evaluation Board, or as a Chief of a Financial or Technical
Evaluation Team.
c. X one. If Yes, provide a summary of your duties and
responsibilities if you served as a Program Manager, Deputy
Program Manager, or Administrative Contracting Officer.
d. X one. Self explanatory.
e. X one. Self explanatory.
f. X one. Self explanatory.
g. If Yes was answered to any of questions 21.a. - f., provide the
contract number(s), contract title(s), and date(s) you last acted on
those contracts.
22. Senior Executive Service, General or Flag Officer Position. X
one. Self explanatory.
SECTION V - PROSPECTIVE EMPLOYER INFORMATION.

13. Do you plan to work while on terminal/transition leave? X one.

23. Position Sought. Provide the name of the civilian company
with which you are seeking employment. Do not abbreviate.

14. U.S. Armed Forces retirement. X one. If your employee status is
a civilian and you previously retired from the U.S. Armed Forces before
becoming a civilian employee of DoD, X Yes. X No if you are a civilian
employee who did not previously retire from the U.S. Armed Forces.

24. Actions Taken. Summarize the actions you have taken
regarding your efforts to become employed with this company for a
specific position. Actions include submitting a resume, being
interviewed, negotiating compensation, etc.

SECTION III - PRIOR ETHICS INFORMATION.

25. Future Job Title. Provide the specific position/job title in which
you anticipate being employed. Provide specific duties and
responsibilities of the position. Include information on how this may
relate to your Government duties.

15. Prior Ethics Advice. X one. Mark Yes if you received any ethics
advice (oral or written) from an attorney concerning employment with a
civilian company. If so, provide the name, officeor organization and
telephone number of the attorney. Mark No if you did not receive any
prior ethics advice concerning employment by a civilian company.
16. Financial Disclosure. X one. Mark No if you have not filed an
OGE Form 450 or SF 278 report within the last two years. Mark Yes if
you have filed either an OGE 450 or SF 278 financial disclosure report
within the last two years. If either the OGE or SF 278 is selected,
provide the position title you were assigned to when you filed the
report.

DD FORM X586 INSTRUCTIONS, 20100322 DRAFT

26. Start Date. Enter date in MM/DD/YYYY format.
27. Additional Comments. Provide any additional information
about your pending employment with a civilian employer that you
want your ethics attorney to know.
28. - 30. Name, Signature and Date. Self explanatory.