Form OGE-201 Request to Inspect or Receive Copies of Executive Branch

U.S. Office of Government Ethics (OGE), Suite 500, 1201 New York Avenue, NW., Washington, DC 20005-3917
Phone: 202-482-9300, FAX: 202-482-9238

Request to Inspect or Receive Copies of Executive Branch Personnel Public Financial
Disclosure Reports or Other Covered Records.
OGE Form 201 (June 2013)

I. Application

Agency Use Only

1. Applicant’s name and address (please print):

Received date:
Filled date:

1a. Office telephone number: (

)

2. Occupation:

ext.

3. If application is for or on behalf of any other
person or organization, give the other's name:

3a. Address of the other person or organization:

T

4. Type of applicant:
❐ news media ❐ private citizen ❐ public interest group ❐ law firm ❐ other private organization ❐ government
5. ❐ Copy of the most recent (or other, specify) Public Financial Disclosure Report Form OGE Form 278/SF 278
requested for the following named individual(s):
a.

F

d.
e.

b.

f.

A

c.

Certain other types of records ("covered records") can also be requested using this form (see Part III below); if you
are requesting another covered record, check this box ❐ and specify which type of record(s):

R

6. Indicate how you wish to receive this request:
❐ Pick up at OGE ❐ By mail (at the address listed above)

(1)
(2)
(3)
(4)

D

I am aware that this request for access to a public financial disclosure report is an official government form (OGE Form 201). In completing this
OGE Form 201, any intentionally false or misleading statement, certification, or response provided in this form is a violation of law punishable by a fine
or imprisonment, or both, under 18 U.S.C. § 1001. Pursuant to section 105(c) of the Ethics in Government Act of 1978 and 5 C.F.R. § 2634.603(f)
of the implementing OGE regulation, it is unlawful for any person to obtain or use a report:
for any unlawful purpose;
for any commercial purpose, other than by news and communications media for dissemination to the general public;
for determining or establishing the credit rating of any individual; or
for use, directly or indirectly, in the solicitation of money for any political, charitable, or other purpose.

The U.S. Attorney General may bring a civil action against any person who obtains or uses a report for any such prohibited purpose as set forth
above. The court may assess against such a person a penalty in any amount not to exceed $11,000. Such remedy shall be in addition to any other
remedy available under statutory or common law.

7. Applicant's signature:

Date:

II. Notice of Action
❐ Copies of the report(s) or other covered record(s) you requested are enclosed.
❐ Picked up by (signature):

Date:

❐ Your request does not comply with the requirements of the statute. Please complete Part I of this form and return
so we may comply with your request.
❐ Fees. If applicable, amount:
(when fees are required, make out a check payable to the U.S. Treasury
and send it to the executive branch agency processing this request form).
(form continued on reverse side)
Form Approved OMB No. 3209-0002

A. Privacy Act Statement
Section 105 of the Ethics in Government Act of 1978, as amended (5 U.S.C. App.), the STOCK Act, and 5 C.F.R. § 2634.603 authorize the
solicitation of the information requested in this form. The primary use of the information on this form is to permit officials of the recipient
agency to consider and process your request for inspection or receipt of a copy(ies) of the OGE Form 278/SF 278 Executive Branch
Personnel Public Disclosure Report and OGE Form 278-T Periodic Transaction Report form(s) or other covered record(s) to which you seek
access. Failure to furnish the information will result in this agency's inability to allow access to, or to provide copies of, the financial disclosure
report form(s) or other record(s) requested. Otherwise, furnishing the requested information is voluntary. The information on this form itself
may be publicly disclosed pursuant to proper request under section 105(b) of the Ethics in Government Act or as otherwise authorized by law.

Additional disclosures of the information on this form 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 judgeissued 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;

T

(6) to the Department of Justice or in certain legal proceedings when the disclosing agency, an 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;

F

(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; and

A

(10) to disclose on the OGE Website and to otherwise disclose to any person, including other departments and agencies, any written ethics
agreements filed with the Office of Government Ethics, pursuant to 5 C.F.R. § 2634.803, by an individual nominated by the President to a
position requiring Senate confirmation when the position also requires the individual to file a public financial disclosure report.

See also the OGE/GOVT-1 executive branchwide Privacy Act system of records.

R

B. Public Burden Information

D

Public burden reporting for this collection of information is estimated to take approximately ten minutes per response, including time for
reviewing instructions, gathering and maintaining the data needed, and completing and reviewing the collection of information. 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 file this form with this official; rather, file it with the appropriate office of the executive branch department or agency from which
you are seeking access to a financial disclosure report or other covered records.
Pursuant to the Paperwork Reduction Act, as amended, an agency may not conduct or sponsor, and no person is required to respond
to, a collection of information unless it displays a currently valid OMB control number (that number, 3209-0002, is displayed here and
in the lower right-hand corner of the front page of this OGE Form 201).

III. Other Covered Records
In addition to requests for access to public OGE Form 278/SF 278 and OGE Form 278-T reports, this form can also be used to request
access to certain other agency records which are covered under the access procedures of section 105 of the Ethics Act and the
implementing OGE regulations ("covered records"). Such other covered records are: (1) certificates of divestiture; (2) Ethics Act
qualified blind trust and qualified diversified trust instruments (other than those provisions which relate to the testamentary disposition of
the trust assets), the list of assets transferred to such trusts (and of assets sold in the case of a qualified blind trust), as well as, in the
case of trust dissolution, the report thereon and the list of trust assets at that time, and the certificates of independence and compliance
with respect to qualified trusts; (3) 18 U.S.C. § 208(b)(1) & (b)(3) waivers granted by the recipient agency (after deletion of any material
withholdable pursuant to the Freedom of Information Act, 5 U.S.C. § 552 (see 18 U.S.C. § 208(d)(1)); (4) other OGE Form 201s;
(5) cover letters for approved gifts reporting waiver requests; and (6) cover letters for approved public reporting waiver requests for
certain less than 130-day special Government employees. If you seek access to any such additional record(s), check the second box in
Part I.5 on the front page and specify the record(s) sought.

OGE Form 201
June 2013