450 Confidential Financial Disclosure Report

OGE Form 450, 5 CFR Part 2634, Subpart I
U.S. Office of Government Ethics (December 2011)
(Replaces June 2008 edition)

Form Approved
OMB No. 3209-0006

CONFIDENTIAL FINANCIAL DISCLOSURE REPORT
Executive Branch

Why Must I File?

When Must I File?

What is the
Reporting Period?

What if I Have
Questions?

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.
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.
New Entrants: Report the required information for the 12 months preceding your
filing of this form.
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
official or go to the Office of Government Ethics web site at www.oge.gov and select
2*( Form 450&RQILGHQWLDO)LQDQFLDO'LVFORVXUH5HSRUW 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.), Executive Order 12674 (as modified by Executive Order 12731), 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 Government officials of your agency, 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 disclosing agency becomes aware of a violation or potential violation of 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 judge-issued 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 inspections; (5) to the Office of Management and
Budget during legislative coordination on private relief legislation; (6) to the Department of Justice or in certain legal proceedings when the
disclosing agency, and employee of the disclosing agency, or the United States is a party to litigation or has an interest in the litigation and
the use of such records is deemed relevant and necessary to the litigation; (7) to reviewing officials in a new office, department or agency
when an employee transfers from one covered position to another, (8) to a Member of Congress or a congressional office in response to an
inquiry made on behalf of an individual who is the subject of the record, and (9) to contractors and other non-Government employees
working for the Federal Government to accomplish a function related to an OGE Governmentwide system of records. This confidential
report will not be disclosed to any requesting person unless authorized by law. See also the OGE/GOVT-2 executive branchwide 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 one hour.
No person 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: Deputy Director for Administration and Information Management, 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.

OGE Form 450, 5 CFR Part 2634, Subpart I
U.S. Office of Government Ethics (December 2011)
(Replaces June 2008 edition)

Date Received by Agency

Form Approved
OMB No. 3209-0006

Use arrow keys to read all text. Tab to complete form.

Page Number

CONFIDENTIAL FINANCIAL DISCLOSURE REPORT
Executive Branch

Employee’s Name (Print last, first, middle initial)

E-mail Address

Position/Title

Grade

Agency

Work Phone

Branch/Unit and Address

Reporting Status

If New Entrant, Date of Appointment to Position
(mm/dd/yy)
New Entrant
Annual
Check box if Special
An SGE is an executive branch officer or employee who is retained, designated, appointed, or
Government Employee (SGE)
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.
II. I have reportable liabilities (debts) for myself, my spouse, or my dependent children.
III. I have reportable outside positions for myself.
IV. I have reportable agreements or arrangements for myself.
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

Yes
Yes
Yes

No
No
No

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

Save

Print

)

OGE Form 450, 5 CFR Part 2634, Subpart I
U.S. Office of Government Ethics (December 2011)
(Replaces June 2008 edition)

Form Approved
OMB No. 3209-0006
Page Number

Employee’s Name (Print last, first, middle initial)

Part I: Assets and Income
Report for Yourself, Spouse, and Dependent Child:
•
Assets held for investment with a value greater than $1,000 at
the end of the reporting period OR assets held for investment
which produced more than $200 in income during the
reporting period, including but 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 general family fund name)
- Holdings of retirement plans, such as 401(k)s or IRAs
(list each holding except diversified mutual funds)
- Holdings of investment life insurance
- Holdings of variable annuities
- Defined benefit pension plans provided by a former
employer (include the name of the employer)

Do Not Report:
•
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
•
Diversified mutual funds, such as ABC Equity
Value Fund or XYZ Large Capital Fund
•
U.S. Government Treasury bonds, bills, notes, and
savings bonds
•
Money owed to you, your spouse, or dependent
child by a spouse, parent, sibling, or child

Also Report:
•
For yourself: (1) all sources of salary, fees, commissions, and
other earned income greater than $200, (2) honoraria greater
than $200, and (3) other non-investment income such as
scholarships, prizes, and gambling income greater than $200
•
For your spouse: (1) all sources of salary, fees, commissions,
and other earned income greater than $1,000, and (2)
honoraria greater than $200

Do Not Report:
•
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.
1

2

3

4

5

No longer
held

OGE Form 450, 5 CFR Part 2634, Subpart I
U.S. Office of Government Ethics (December 2011)
(Replaces June 2008 edition)

Form Approved
OMB No. 3209-0006

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

Add Page

OGE Form 450, 5 CFR Part 2634, Subpart I
U.S. Office of Government Ethics (December 2011)
(Replaces June 2008 edition)

Form Approved
OMB No. 3209-0006

Employee’s Name (Print last, first, middle initial)

Page Number

Part II: Liabilities
Report for Yourself, Spouse, and Dependent
Child:
• A liability over $10,000 owed at any time
during the reporting period, other than a
loan from a financial institution or business
entity granted on terms made available to
the general public
• A loan over $10,000 from an individual,
such as a friend or a business associate

Do Not Report:
•
•
•

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

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:
• 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

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

Add Page

OGE Form 450, 5 CFR Part 2634, Subpart I
U.S. Office of Government Ethics (December 2011)
(Replaces June 2008 edition)

Form Approved
OMB No. 3209-0006

Employee’s Name (Print last, first, middle initial)

Page Number

Part IV: Agreements or Arrangements
Report Your Agreements or Arrangements for:
•
Continuing participation in an employee pension or benefit plan maintained
by a former employer
•
A leave of absence
•
Future employment, including date you accepted employment offer
•
Continuation of payment by a former employer (including severance
payments)

Do Not Report:
•
Any agreement or arrangement
related to your employment by the
Federal Government
•
Spouse’s and dependent child’s
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:
•
Travel-related reimbursements (items such as lodging,
transportation, and food) totaling more than $350* from any one
source during the reporting period; include where you traveled,
the purpose, and date(s) of the trip
•
Any other gifts totaling more than $350* from any one source
during the reporting period
*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 $140 or less
3. Add the value of those items valued at more than $140; if the total
is more than $350, then you must list those items on this form

Do Not Report:
•
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

Reportable Information – Go to the last page to see examples of how to report gifts and travel reimbursements.
Source

Description

1

2

3

Add Page

OGE Form 450, 5 CFR Part 2634, Subpart I
U.S. Office of Government Ethics (December 2011)
(Replaces June 2008 edition)

Form Approved
OMB No. 3209-0006

EXAMPLES
Part I: 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.
XYZ Japan Fund (Example of sector mutual fund)
OGE Energy (Example of stock that produced more than $200 in capital gains)
(S) OGC Communications (Example of stock held in a 401(k) plan)
ABC Healthcare Fund (Example of sector fund held in a variable annuity)
Rental Condo, Anchorage, AK (Example of investment real estate)
Bryggadune University – former employer
(S) Express Medical Clinic – employer
Association of Accountants – honoraria

No longer
held

Part II: Liabilities
Name of creditor (city and state)
John Jones (Denver, CO)
ANW Investment Company (San Francisco,
CA)

Type of liability (personal loan, margin account, etc.)
Personal loan from a friend
Margin account

Part III: Outside Positions
Organization
(city and state)
Bryggadune University
(Memphis, TN)
ISK Family Trust
(Boynton Beach, FL)
Scenic Rivers Association
(Nashville, TN)

Type of organization

Position

Educational institution

Professor

Family Trust

Trustee

Non-profit environmental
organization

Member, Board of
Directors

No longer
held

Part IV: Agreements or Arrangements
Entity with which you have an agreement
or arrangement (include city and state
where entity is located)
Dee, Jones & Smith
(San Diego, CA)

Terms of Agreement or Arrangement

Hartford & Brown
(San Diego, CA)

Employment agreement with Hartford & Brown. Starting work as attorney in
July 2012. Entered into agreement in October 2011. (Example of
agreement for future employment)

Will receive pension benefits (defined benefit plan) (Example of continuing
participation in an employee pension or benefit plan by a former employer)

Part V: Gifts and Travel Reimbursements
Source
Dee, Jones & Smith
CGH Culinary Institute

Description
Leather briefcase
(Example of a gift totaling more than $350 from one source)
Airline ticket, hotel room, and meals incident to culinary seminar in Tokyo,
Japan from May 1-5, 2011 (Example of travel reimbursement)