Form ACUS Form 1 ACUS Form 1 Substitute Confidential Employment and Financial Disclos

OMB Control No. 3002 - 0003

Expiration Date: March 31, 2011

ACUS Form 1

Administrative Conference of the United States

Public Member Confidential Employment

And Financial Disclosure Report

Public members of the Administrative Conference of the United States (ACUS) are deemed to be special government employees within the meaning of 18 U.S.C. § 202(a) and, therefore, are subject to confidential financial disclosure requirements of the Ethics in Government Act, 5 U.S.C app. § 107, and U.S. Office of Government Ethics (OGE) regulations.

This form is a substitute for OGE Standard Form 450 that ACUS public members otherwise would be required to file. It was approved by the Director of the Office of Government Ethics following a determination by the ACUS Chairman, pursuant to 5 C.F.R § 2634.905(a), that greater disclosure by public members is not required because the duties of a member make remote the possibility that a real or apparent conflict of interest will occur.

As required by the Ethics in Government Act, 5 U.S.C. app. § 107(a); Executive Order 12674, § 201(d); and OGE regulations, 5 C.F.R. § 2634.901(d), this report will be held in strict confidence.

Member’s name: _________________________________________________________

E-mail address: __________________________________________________________

Administrative Conference committee: ______________________________________

Employer: _______________________________________________________________

Occupation or position title: ________________________________________________

PART II: OUTSIDE POSITIONS

Report any outside positions, whether or not compensated, which you held outside the U.S. Government in the last year but only if such positions involved responsibilities that relate in some way to the subject matter of any item on the agenda of the upcoming ACUS plenary session or of a meeting of an ACUS committee of which you are a member. You need not report any positions of your spouse or dependent children.

Note: Positions include but are not limited to those of an employee, officer, director, trustee, general partner, proprietor, representative, or consultant of any corporation, firm, partnership, or other business, enterprise or any non-profit organization or educational institution. Exclude positions with religious, social, fraternal, or political entities or those solely of an honorary nature.

None______

1._____________________________________________________________________

2._____________________________________________________________________

3._____________________________________________________________________

PART III: AGREEMENTS AND ARRANGEMENTS

Report below any current agreements or arrangements for future employment, leaves of absence, payment by a former employer (including severance payments), or continuing participation in an employee benefit plan, but only if such agreements or arrangements relate in some way to the subject matter of any item on the agenda of the upcoming ACUS plenary session or of a meeting of an ACUS committee of which you are a member. You need not report any agreements or arrangements of your spouse or dependent children.

None______

1._____________________________________________________________________

2._____________________________________________________________________

3._____________________________________________________________________

PART IV: ASSETS, INCOME AND LIABILITIES

Identify for you, your spouse, and dependent children: (1) each asset held for investment or the production of income that exceeds $1,000 in value (excluding accounts in banks, savings and loans and similar depository institutions and U.S. Government obligations, such as U.S savings bonds and government-issued securities); (2) each asset or source of income which generated over $200 in income in the previous year; and (3) any liabilities over $10,000 (excluding a residential mortgage, consumer loans, and liabilities owed to immediate family members), but only if such assets, income, and liabilities relate in some way to the subject matter of any item on the agenda of the upcoming ACUS plenary session or of a meeting of an ACUS committee of which you are a member. Report only the identity and nature of income; do not include the amount or value of assets, income, or liabilities.

Note: This part is intended to require no greater disclosure than is required by OGE Standard Form 450, which would require disclosure of assets, income and liabilities regardless of their relevance to ACUS matters. However, because OGE’s regulations on disclosure of assets, income, and liabilities contain additional exclusions from reporting, members are advised to consult with the ACUS General Counsel/Designated Agency Ethics Official if they have questions about the reporting of assets, income, and liabilities described above.

None_____

1._____________________________________________________________________

2._____________________________________________________________________

3._____________________________________________________________________

I certify that the statements I have made on this form are true, complete, and correct to best of my knowledge.

Signature of Public Member_________________________________________ _ Date______

Signature of Designated Agency Ethics Official___________________________ Date______

Privacy Act Statement

Title I of the Ethics in Government Act of 1978 (5 U.S.C. App.), Executive Order 12674, and 5 CFR Part 2634, Subpart I, of the Office of Government Ethics regulations require the reporting of this information. The primary use of the information on this form is for review by the Administrative Conference, to determine compliance with applicable Federal conflict of interest laws and regulations. Additional disclosures of the information on this report may be made: (1) to a Federal, State, or local law enforcement agency if the agency becomes aware of a violation of the law or regulation; (2) to a court or party in a court or federal administrative proceeding if the Government is a party or in order to comply with a subpoena; (3) to a source when necessary to obtain information relevant to a conflict of interest investigation or decision; (4) to the National Archives and Records Administration or the General Services Administration in records management and inspections; (5) to the Office of Management and Budget during legislative coordination on private relief legislation; and (6) in response to a request for discovery or for the appearance of a witness in a judicial or administrative proceeding, if the information is relevant to the subject matter. This confidential report will not be disclosed to any requesting person unless authorized by law.

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 appropriate authority. Knowing and willful falsification of information required to be reported may also subject you to criminal prosecution.

Paperwork Reduction Act Statement

The average burden for each response to this information collection is estimated to be less than 15 minutes. Any comments concerning the accuracy of this burden estimate and any suggestions for reducing this burden may be directed to the Office of the Chairman of the Administrative Conference.

An agency may not conduct or sponsor and a person is not required to respond to a collection of information unless it displays a current valid OMB control number.