Executive Branch Qualified Trust Documents (see items 1. and 2. in Supporting Statement for precise titles of all documents)

Form Approved: OMB No. 3209-0007
(Revised 9/2013)

BLIND TRUST COMMUNICATIONS

Expedited procedure for securing approval of proposed communications.
Under the requirements of the Ethics in Government Act, the regulations of the U.S.
Office of Government Ethics, and the provisions of trust instruments which have been approved
by this Office, all communications between the trustee of a qualified trust and the interested
parties or their representatives must be in writing and specifically approved by the Director of
the U.S. Office of Government Ethics prior to being transmitted. No oral communications are
permitted. The only exceptions to the prior approval requirement for written communications
relate to quarterly and annual reports conforming to standard formats which are distributed by
the trustee.
The most expedient manner of securing prior approval is to transmit a copy of the
proposed communication to this Office by fax: 202-482-9237. Address the cover sheet to the
attention of the attorney assigned to your trust.
Our staff is always available to discuss a proposed communication or any other concerns
which may arise by telephone: 202-482-9300. Please direct your telephone calls to the attorney
assigned to your trust.

January 15, 2013

MODEL QUARTERLY REPORT TO SETTLOR

Honorable Marcus M. Mandarin
Chairman, Regulatory Commission
Washington, DC 20415
Re: Qualified Blind Trust
of March 20, 2011

Dear Mr. Mandarin:
Pursuant to Paragraph (A) of Article SIXTH of your Qualified Blind Trust, this is to
inform you that as of December 31, 2012, the aggregate market value of the assets representing
your interest in the Trust was $1,894,532.00.
Sincerely,

Metropolis Trust Company
by:

__________________________
Trust Officer

cc:

Director, U.S. Office of Government Ethics
Suite 500
1201 New York Avenue, NW.
Washington, DC 20005-3917

January 15, 2013

MODEL REPORT OF ASSET SOLD OR VALUE LESS THAN $1,000

Honorable Marcus M. Mandarin
Chairman, Regulatory Commission
Washington, DC 20415
Re: Qualified Blind Trust
of March 20, 2011

Dear Mr. Mandarin:
Pursuant to Article Fourth of your Qualified Blind Trust, this is to inform you that as of
December 31, 2012, ____________ has been completely disposed of or has a value of less than
$1,000.
Sincerely,

Metropolis Trust Company
by:

__________________________
Trust Officer

cc:

Director, U.S. Office of Government Ethics
Suite 500
1201 New York Avenue, NW.
Washington, DC 20005-3917

January 15, 2013

MODEL QUARTERLY REPORT TO SETTLOR

Honorable Marcus M. Mandarin
Chairman, Regulatory Commission
Washington, DC 20415
Re: Qualified Diversified
Trust of March 20, 2011

Dear Mr. Mandarin:
Pursuant to Paragraph (A) of Article SEVENTH of your Qualified Diversified Trust, this
is to inform you that as of December 31, 2012, the aggregate market value of the assets
representing your interest in the Trust was $1,894,532.00.
Sincerely,

Metropolis Trust Company
by:

__________________________
Trust Officer
cc:

Director, U.S. Office of Government Ethics
Suite 500
1201 New York Avenue, NW.
Washington, DC 20005-3917

January 15, 2013

MODEL ANNUAL REPORT TO SETTLOR

Honorable Marcus M. Mandarin
Chairman, Regulatory Commission
Washington, DC 20415
Re: Qualified Blind Trust
of March 20, 2011

Dear Mr. Mandarin:
Pursuant to Paragraph (B) of Article SIXTH of your Qualified Blind Trust, your K-1 for
the Trust with respect to the calendar year 2012 is hereby transmitted to you.
Sincerely,

Metropolis Trust Company
by:

__________________________
Trust Officer
Enclosure
cc (with enclosure):
Director, U.S. Office of Government Ethics
Suite 500
1201 New York Avenue, NW.
Washington, DC 20005-3917

January 15, 2013
MODEL ANNUAL REPORT TO SETTLOR

Honorable Marcus M. Mandarin
Chairman, Regulatory Commission
Washington, DC 20415
Re: Qualified Diversified
Trust of March 20, 2011

Dear Mr. Mandarin:
Pursuant to Paragraph (B) of Article SEVENTH of your Qualified Diversified Trust, this
is to inform you that for the calendar year 2012, $46,589.54 was paid to you in respect of such
Trust (or applied for your benefit therefrom).
Sincerely,

Metropolis Trust Company
by:

__________________________
Trust Officer
Enclosure
cc:

Director, U.S. Office of Government Ethics
Suite 500
1201 New York Avenue, NW.
Washington, DC 20005-3917

Privacy Act Statement
Section 102(f) of the Ethics in Government Act of 1978 as amended (the “Ethics Act”),
5 U.S.C. Appendix, § 102(f), and subpart D of 5 C.F.R. part 2634 of the regulations of the U.S.
Office of Government Ethics (OGE) require the reporting of this information for the
administration of qualified trusts under the Act. The primary use of the information on the trust
instrument prepared based in part upon this model draft document is for review by Government
officials of OGE and the agency of the Government employee for whom the trust is being
established to determine compliance with applicable Federal laws and regulations as regards
qualified trusts. Additional disclosures of the information in the trust document itself may be
made:
1) To disclose pertinent information to the appropriate Federal, State, or local agency
responsible for investigating, prosecuting, enforcing, or implementing a statute, rule,
regulation, or order where the disclosing agency becomes aware of an indication of a
violation or potential violation of civil or criminal law or regulation.
2) To disclose information to another Federal agency, to a court, or a party in litigation
before a court or in an administrative proceeding being conducted by a Federal agency,
either when the Government is a party to a judicial or administrative proceeding or in
order to comply with a subpoena issued by a judge of a court of competent jurisdiction.
3) To disclose information to any source when necessary to obtain information relevant to a
conflict-of-interest investigation or determination.
4) By the National Archives and Records Administration or the General Services
Administration in records management inspections conducted under authority of
44 U.S.C. 2904 and 2906.
5) To disclose information to the Office of Management and Budget at any stage in the
legislative coordination and clearance process in connection private relief legislation as
set forth in OMB Circular No. A-19.
6) To disclose information to the Department of Justice, or in a proceeding before a court,
adjudicative body, or other administrative body before which OGE is authorized to
appear, when: OGE; or an employee of OGE in his or her official capacity, or any
employee of OGE in his or her individual capacity (where the Department of Justice or
OGE has agreed to represent the employee); or the United States (when OGE determines
that litigation is likely to affect OGE), is a party to litigation or has an interest in such
litigation, and the use of such records by the Department of Justice or OGE is deemed by
OGE to be relevant and necessary to the litigation provided, however, that the disclosure
is compatible with the purpose for which such records were collected.
7) To disclose the public financial disclosure report and any accompanying documents to
reviewing officials in a new office, department or agency when an employee transfers or
is detailed from a covered position in one office, department or agency to a covered
position in another office, department or agency.

8) To disclose information 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.
9) To disclose the information to contractors, grantees, experts, consultants, detailees, and
other non-Government employees performing or working on a contract, service, or other
assignment for the Federal Government, when necessary to accomplish an agency
function related to this system of records.
For additional information please see OGE/GVT-1 Governmentwide Privacy System of Records.

Penalties
Knowing or willful falsification of information on the trust document prepared from this
model draft or failure to file or report information required to be reported under Title I of the
Ethics Act and 5 C.F.R. part 2634 of the OGE regulations may lead to disqualification as a
trustee or other fiduciary as well as possible disqualification of the underlying trust itself.
Knowing and willful falsification of information required under the Ethics Act and the
regulations may also subject you to criminal prosecution.

Public Burden Information and Paperwork Reduction Statement
This collection of information is estimated to take an average of 20 minutes per
communication letter, given the estimated amount of time deemed necessary to prepare a
communication. You can send comments regarding the burden estimate or any other aspect of
this collection of information, including suggestions for reducing this burden, to: Program
Counsel, U.S. Office of Government Ethics, Suite 500, 1201 New York Avenue, NW.,
Washington, DC 20005-3917. Do not send your completed communication letter to this address;
rather, see the remainder of the instructions to this model set of drafts.