Form OGE Form 278 OGE Form 278 Executive Branch Personnel Public Financial Disclosure R

OGE Form 278
Executive Branch Personnel
PUBLIC FINANCIAL
DISCLOSURE REPORT
Instructions for Completing OGE 278

Schedule C, Part II (Agreements or Arrangements) Show any agreements or arrangements as of the date of
filing.

• Schedule D - The reporting period is the preceding two
calendar years and the current calendar year up to the date
of filing.
Scope of Disclosure

I. Introduction
Reporting Periods
Incumbents: Complete Schedules A, B, C, and Part I of
D. The reporting period is the preceding calendar year,
except Part II of Schedule C and Part I of Schedule D
where you must also include any positions held and
agreements or arrangements made from the beginning of
the filing year until the date you file. Schedule B need not
include transactions made, or gifts or reimbursements
received, during a period when the filer was not a Federal
employee.
Termination Filers: Complete Schedules A, B, C, and
Part I of D. The reporting period begins at the end of the
period covered by your previous filing and ends at the
date of termination of Government employment in the
position.
Nominees, New Entrants and Candidates for President and Vice President: Complete Schedules A, C,
and D (candidates do not file Part II of Schedule D), as
follows:
• Schedule A- The reporting period for income (BLOCK
C) is the preceding calendar year and the current calendar year up to the date of filing. Value assets in BLOCK
B as of any date you choose that is less than 31 days
before the date of filing.

Schedule C, Part I(Liabilities) - The reporting period
is the preceding calendar year and the current calendar
year up to any date you choose that is less than 31 days
before the date of filing.

The extent of the reporting requirement is noted in each
schedule. The various schedules of this form require
reporting of your financial interests and activities, both
in the U.S. and abroad, except as otherwise noted. In
addition to your individual financial information, you are
required to report information concerning your spouse
and dependent children in several schedules of the form.
However, no report is required with respect to your
spouse if he or she is living separate and apart from you
with the intention of terminating the marriage or providing for permanent separation. In addition, no report is
required with respect to any income or obligations of an
individual arising from the dissolution of marriage or
permanent separation from a spouse. There are other
exceptions to the reporting of assets and income, transactions, and liabilities of a spouse or dependent child which
are discussed in the instructions applicable to those
subjects.
A basic premise of the statutory financial disclosure
requirements is that those having responsibility for review of reports filed pursuant to the Ethics in Government Act or permitted public access to reports must be
given sufficient information by reporting individuals
concerning the nature of their outside interests and activities so that an informed judgment can be made with
respect to compliance with applicable conflict of interest
laws and standards of conduct regulations. Therefore, it
is important that you carefully complete the attached
form. This report is a safeguard for you as well as the
Government, in that it provides a mechanism for determining actual or potential conflicts between your public
responsibilities and your private interests and activities
and allows you and your agency to fashion appropriate
protections against such conflicts when they first appear.

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A Presidential nominee to a position requiring the advice
and consent of the Senate shall file with the Senate
committee considering the nomination an amendment to
the initial report, which shall update all items of earned
income and honoraria through the period ending no
earlier than 5 days before the scheduled date of the
Senate committee hearing on the nomination. This update shall be provided in the manner requested by the
Senate committee considering the nomination. Copies
shall be provided to OGE and your agency ethics
official.
Definition of Terms
• Category of Amount
Reportable financial interests are disclosed either by
actual amount or by category of amount, depending on
the interest, as specified by the form. You may, but you
are not required to, indicate an actual amount where the
form provides for a category of amount or value.
• Dependent Child
The term “dependent child” means your son, daughter,
stepson, or stepdaughter if such person is either: (1)
unmarried, under age 21, and living in your household,
or (2) a “dependent” of yours within the meaning of
section 152 of the Internal Revenue Code of 1986.
• Excepted Investment Fund
An excepted investment fund is a mutual fund, common
trust fund of a bank, pension or deferred compensation
plan, or any other investment fund, which is widely held;
publicly traded (or available) or widely diversified; and
under circumstances where you neither exercise control
over nor have the ability to exercise control over the
financial interests held by the fund. A fund is widely
diversified when it holds no more than 5% of the value of
its portfolio in the securities of any one issuer (other
than the U.S. Government) and no more than 20% in any
particular economic or geographic sector.

• Gifts
See instructions for Schedule B, Part II.B.
• Honoraria
The term “honoraria” means payments of money or
anything of value to you or your spouse for an appearance, speech, or article, excluding necessary travel expenses. See 5 U.S.C. app. § 505(3).
• Personal Savings Account
The term “personal savings account” includes a certificate of deposit, a money market account, or any other
form of deposit in a bank, savings and loan association,
credit union, or similar financial institution.
• Trusts (Qualified and Excepted)
See instructions for Schedule A, Part II.B., and 5 C.F.R.
Part 2634, Subpart D.



Value
You may use any one of the methods described below, in
determining fair market value:

Option 5 - the year-end book value of non-publicly
traded stock, or the year-end exchange value of corporate
stocks, or the face value of corporate bonds or comparable securities;

• Officers or employees in any other positions determined by the Director of the Office of Government
Ethics to be of equal classification to above GS-15;
• Administrative law judges;

Option 6 - the net worth of your interest (as in a business
partnership or other jointly held business interest);
Option 7 - the equity value of your interest (as in a solely
owned business or commercial enterprise); or
Option 8 - exact value (e.g., personal savings accounts)
or any other recognized indication of value (such as last
sale on a stock exchange).
II. Who Must File
a. Candidates for nomination or election to the office of
President or Vice President.
b. Presidential nominees to positions requiring the advice and consent of the Senate, other than those nominated for judicial office or as a Foreign Service Officer
or for appointment to a rank in the uniformed services at
a pay grade of O-6, or below.

• Employees in the excepted service in positions which
are of a confidential or policy-making character, unless
by regulation their positions have been excluded by the
Director of the Office of Government Ethics ;
• The Postmaster General, the Deputy Postmaster General, each Governor of the Board of Governors of the
U.S. Postal Service and officers or employees of the U.S.
Postal Service or Postal Rate Commission in positions
for which the rate of basic pay is equal to or greater than
120% of the minimum rate of basic pay for GS-15
of the General Schedule;
• The Director of the Office of Government Ethics and
each designated agency ethics official; and
• Civilian employees in the Executive Office of the
President (other than special Government employees)
who hold commissions of appointment from the
President.

c. The following newly elected or appointed officials:
d. Incumbent officials holding positions referred to in
section II.c. of these instructions if they have served
61 days or more in the position during the preceding
calendar year.

Option 1 - any good faith estimate of the value of the
property if the exact value is unknown or not easily
obtainable;

• The President;

Option 2 - value based upon a recent appraisal of the
property interest;

• Officers and employees (including special Government
employees, as defined in 18 U.S.C. § 202) whose positions are classified above GS-15 of the General Schedule, or the rate of basic pay for which is fixed, other than
under the General Schedule, at a rate equal to or greater
than 120% of the minimum rate of basic pay for GS-15
of the General Schedule.

e. Officials who have terminated employment after having served 61 days or more in a calendar year in a
position referred to in section II.c. and have not accepted
another such position within 30 days thereafter.

• Members of the uniformed services in pay grade O-7 or
above;

a. Within 30 days after becoming a candidate for nomination or election to the office of President or Vice

Option 3 - the purchase price of your property interest,
or estimated retail price of a gift;
Option 4 - the assessed value of the property for tax
purposes, adjusted to reflect current market value if the
tax assessment is computed at less than 100% of current
value;

• The Vice President;

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III. When to File

President, or by May 15 of that calendar year, whichever
is later, but at least 30 days before the election, and on or
before May 15 of each succeeding year an individual
continues to be a candidate.
b. At any time after the President or President-elect has
publicly announced an intention to nominate an individual referred to in section II.b. of these instructions, but
no later than 5 days after the President transmits the
nomination to the Senate.
c. Within 30 days after assuming a position described in
section II.c. unless such an individual has left another
such position within 30 days prior to assuming the new
position, or has already filed a report with respect to
nomination for the new position (section II.b.) or as a
candidate for the position (section II.a.).
d. No later than May 15th annually, in the case of those
in a position described in section II.d.
e. In the event an individual terminates employment in
the position and does not accept another position described in section II.c. within 30 days, the report must be
filed no later than the 30th day after termination.
f. Extensions. An employing agency may grant an extension of time of up to 45 days to a filer to file any report
under sections III. c.-e. above (the FEC for any report
under section III. a. above). OGE may grant an additional
extension of time up to 45 days to file any such report.
g. Fee for Late Filing. Any individual who is required to
file this report and does so more than 30 days after the
date the report is required to be filed, or, if an extension
is granted, more than 30 days after the last day of the
filing extension period, shall be subject to a $200 late
filing fee. A report is considered to be filed when it is
received by the agency. Unless waived by OGE, such fee
will be collected by the filer's agency, for deposit with
the U.S. Treasury.

IV. Where to File
a. Candidates for President and Vice President, with the
Federal Election Commission.
b. The President and Vice President, with the Office of
Government Ethics.
c. Members of a uniformed service, with the Service
Secretary concerned.
d. All others, with the designated agency ethics official,
or that official's delegate, at the agency in which the
individual serves, will serve or has served.
e. In the case of individuals nominated by or to be
nominated by the President to positions requiring confirmation of the Senate, see 5 C.F.R. Part 2634 for expedited procedures and filing location.
V. General Instructions
a. This form consists of the front page and four Schedules. If possible, use a black ink pen or typewriter to fill
out your report. You must complete each Part of all
Schedules as required. If you have no information to
report in any Part of a Schedule, you should indicate
“None.” If you are not required to complete Schedule B
or Part II of Schedule D, you should leave it blank.
Schedule A combines a report of income items with the
disclosure of certain property interests. Schedule B deals
with transactions in real property or certain other assets,
as well as gifts and reimbursements. Schedules C and D
relate to liabilities and employment relationships. After
completing the first page and each Part of the Schedules
(including extra sheets of any Schedule where continuation pages are required for any Part), consecutively
number all pages.

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b. The information to be disclosed is only that which the
Ethics in Government Act of 1978, as amended (the Act)
and 5 C.F.R. Part 2634 specifically require. You may,
however, include any additional information, beyond
those requirements, that you wish to disclose for purposes of clarification. Disclosure of information does
not authorize any holdings, income, honoraria, liabilities, transactions, gifts, reimbursements, affiliations or
positions otherwise prohibited by law, Executive order,
rule or regulation.
c. Combine on one form the information applicable to
yourself, your spouse and dependent children; or if more
convenient, use separate schedules to report the required
information applicable to family members. You may, if
you desire, distinguish any entry for a family member by
preceding the entry with an (S) if it is for a spouse or a
(DC) if it pertains to a dependent child. Joint assets may
be indicated by a (J). See 5 C.F.R. Part 2634, Subpart C,
for exclusions in the case of separation or divorce.
d. Definitions of the various terms used in these instructions and detailed information as to what is required to be
disclosed are contained in 5 C.F.R. Part 2634.
e. In the case of references to entities which are operating
trades or businesses which do not have listed securities,
you must provide sufficient information about these
private entities to give the reviewers of your disclosure
report an adequate basis for the conflicts analysis required by the Act. Thus, you must disclose the location
and primary trade or business of private entities, as well
as attributed interests and activities not solely incidental
to such a primary trade or business. For instance, if your
family swimming pool services corporation incurs a
liability to purchase an apartment house for investment
in addition to its pool services business, you will have to
report the apartment house investment as part of the
nature of the business of the family corporation.

f. In the case of references to entities which are investment funds such as mutual or pension funds (whether
public or private), you must disclose the portfolio holdings and all other items such as transactions and liabilities to the extent otherwise required for reportable interests, unless the entity is an “excepted investment fund.”
See Definition of Terms above.
g. If you need assistance in completing this form, contact
the designated agency ethics official of the agency in
which you serve, will serve, or have served.
Schedule A
I. General Instructions
Two of the general disclosure requirements of the Act
concern certain interests in property (generally referred
to here as assets) and items of income. Schedule A is
designed to enable you to meet both of these reporting
requirements. Generally a description of your, your
spouse's, and your dependent child's assets and sources
of income is required to be listed in BLOCK A of the
Schedule. Reading from left to right across the page
from each description of the asset or income source, you
will be able to report in BLOCK B the value of each asset,
and in BLOCK C the type and amount of income
generated by that asset or received from the non-asset
source.
On Schedule A are four examples which are representative of the reporting scheme of this Schedule. The first
example represents the proper method of reporting stock
of Central Airlines Company held at the end of the
reporting period which then had a value of $75,000. The
individual had also received dividends of $1,500, reported in BLOCK C. If the Central Airlines stock had
been sold, there would be a check in the “None (or less
than $1,001)” column in BLOCK B if the individual no
longer owned any of the stock at the end of the reporting
period, and there would be an entry for capital gains as
well as dividends in BLOCK C if they were realized

during the period. The second example represents the
proper method of reporting the source of $130,000 of
earned income from private law practice, as well as
$18,500 the reporting individual maintained in the capital account in the law firm at the end of the reporting
period.
The third example represents acceptable reporting of an
investment fund which is widely held, widely diversified
(or publicly traded) and independently managed. Because it meets these requirements, no individual assets of
the fund need to be reported, and the type of income does
not need to be broken into dividends, interest, or capital
gains as long as the column for “excepted investment
fund” is marked. The fourth example reports a mutual
fund held in an IRA from which the filer has accrued
dividends of $10,000.
Normally you will have to list an item only once in
BLOCK A with all other value and income information
associated with that item shown on the same line to the
right. However, when you have a number of different
kinds of financial arrangements and income involving
one entity, a full disclosure of all the required information for that entity may require more than one line. You
may always use more than one line for clarification if you
choose.
II. Property Interests and Assets
(BLOCKS A and B)
A. Items to Report
Report the identity and category of valuation of any
interest in property (real or personal) held by you, your
spouse or dependent child in a trade or business, or for
investment or the production of income which has a fair
market value which exceeds $1,000as of the close of the
reporting period. These interests include, but are not
limited to, stocks, bonds, pension interests and annuities,
futures contracts, mutual funds, IRA assets, tax shelters,
beneficial interests in trusts, personal savings or other
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bank accounts, real estate, commercial crops, livestock,
accounts or other funds receivable, and collectible items
held for resale or investment. Exceptions: Exclude your
personal residence (unless rented out) and any personal
liability owed to you, your spouse or dependent child by
a spouse or dependent child, or by a parent, brother, sister
or child of you, your spouse, or dependent child. Exclude
any retirement benefits (including the Thrift Savings
Plan) from Federal Government employment and any
social security benefits. Exclude also any deposits aggregating $5,000 or less in personal savings accounts in a
single financial institution.
With respect to assets of a spouse or a dependent child,
do not report items:
(1) which represent your spouse's or dependent child's
sole financial interest or responsibility and of which you
have no knowledge;
(2) which are not in any way, past or present, derived
from your income, assets, or activities; and
(3) from which you neither derive, nor expect to derive,
any financial or economic benefit.
Note: It is very difficult for most individuals to meet all
three parts of this test, especially (3). For instance, if you
file a joint tax return with your spouse, you derive a
financial or economic benefit from the items involved
and you are charged with knowledge of those items. A
trust for the education of your minor child would also
convey a financial benefit to you. Therefore, those asset
and income items do not fit the test.
A personal residence held for investment or production
of income, such as a summer home rented during parts of
the year, must be reported.
Intermittent sales from personal property such as collections of antiques or art holdings demonstrate that the
items are held for investment or the production of income
and should therefore be reported.

B. What to Show on the Form
Enter the identity of the asset in BLOCK A and then show
the value in BLOCK B. Only the category of value,
rather than the actual value of the property interest
or asset, must be shown. You need not disclose which
valuation methods you used.
For assets such as stocks, bonds, and securities,
report
any holdings directly held or attributable to you, your
spouse or dependent child from one source totaling
more than $1,000 in value. Identify the holding and
show the category of value. If you hold different types
of securities of the same corporation (e.g., bonds and
stocks of “X” Corporation), these holdings should be
considered as being from the same source for purposes of
determining whether the aggregate value of the interest
is below or above the $1,000 threshold value. Report
personal savings accounts only if they aggregate more
than $5,000 in a single financial institution.
If you have an interest in an investment fund or pool
which is an “excepted investment fund” (see Definition
of Terms above), you need only identify the interest by
giving the complete name of the fund, rather than identifying the underlying assets as well.
To report interests of you, your spouse, or dependent
child in a business, a partnership, or joint venture, or
the ownership of property held for investment or the
production of income, identify the character of the
ownership interest, and the nature and location of the
business or interest, unless it is a publicly traded
security. For example, the entry for a holding of farm
land might show, under BLOCK A... “sole ownership of
100 acres of unimproved dairy farmland Ln 0DGLVRQ
County, Wisconsin.”
You must disclose the primary trade or business of nonpublic entities, as well as interests and activities
not solely incidental to such a trade or business. For

example, if your family is involved in a private real
estate investment business but as a side interest buys
stock through the business in a bank, you must disclose
that in addition to real estate (by type and general
location), the family business holds an interest in a bank.
For an IRA (Individual Retirement Account), indicate
the value of each underlying asset, as well as the income
derived therefrom (even though deferred for Federal tax
purposes) in accordance with section IV below, to
enable the reviewer to evaluate compliance with applicable laws and regulations. If the IRA were invested
solely in a mutual fund such as “Templeton World Fund,
Inc.” and the investment properly disclosed in Schedule
A, that would be sufficient identification of the asset,
since for most reporting individuals that fund would be
an “excepted investment fund.” If, however, the IRA
had an individual or privately managed portfolio, detailed disclosure of the portfolio would be required on
Schedule A in the same amount of detail as if each
investment were directly held.
With respect to trusts in which a vested beneficial
interest in principal or income is held, or as to which
you serve as trustee, report trust interests and trust
assets which had a value in excess of $1,000.
See
5 C.F.R. Part 2634 for more information about vested
interests.
You need not report the identity of assets of a trust of
which you, your spouse or dependent children are the
beneficiaries if the interest is:
1. a “qualified blind trust” or “qualified diversified
trust,” which has been certified by the Office of Government Ethics, in accordance with 5 C.F.R. Part 2634,
Subpart D, or
2. an “excepted trust,” that is, one which:
A. was not created by you or your spouse or dependent
children, and

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B. has holdings or sources of income of which you,
your spouse and dependent children have no knowledge.
In the case of these special types of trusts, you should
show in BLOCK A the identity of the trust, including the
date of creation, and next to BLOCK C, the classification
of the trust as a “qualified trust” or an “excepted trust.”
You should also report in BLOCK B the category of the
total cash value of the interest in a qualified blind or
qualified diversified trust, unless the trust instrument was
executed prior to July 24, 1995, and precludes the beneficiary from receiving information on the total cash value
of any interest therein. (The category of amount of the
trust income, if it exceeded $200, must also be reported
in BLOCK C, in accordance with section IV below.)
Note: You are not permitted by the statute to “create” an
excepted trust by instructing a trustee not to divulge
information or otherwise avoiding previous sources of
knowledge upon entering Government service.
Do not report a trust of which your spouse or dependent
child is a beneficiary that meets the three part test set forth
in the second paragraph under II.A. A trust that does not
fit that exception may still be an excepted trust under this
section; in such case, it must be reported, but the assets
need not be identified.
Except for the special trusts or funds referred to above,
you must identify each individual investment held by a
trust or fund, which had a value in excess of $1,000. For
example, in BLOCK A an entry such as “trust held by
First National Bank (Boston, MA) consisting of ITT
stock, U.S. Treasury certificates, and Dallas Municipal
Bonds” might be made. In BLOCK B the applicable
value of each trust asset would be entered. (As described
under IV.B.6. Trust Income, below, the income from
each asset would be entered in BLOCK C as well as
income from assets of the trust sold during the reporting
period.)

III. Earned and Other Non-Investment Income
(BLOCKS A and C)
A. Items to Report
For yourself, report the identity of the source in BLOCK
A and the type and actual amount in BLOCK C of
non-investment income exceeding $200 from any one
source. Such income includes fees, salaries, commissions, compensation for personal services, retirement
benefits, and honoraria. Report these items on the same
line as related interests in property, if any.
For your spouse, report the source, but not the amount,
of non-investment income exceeding $1,000 and the
source, amount and date of honoraria exceeding $200
from any one source. No report of the earned or other
non-investment income of your dependent children is
required.
Exclude for yourself and spouse income from employment by the United States Government and from any
retirement system of the United States (including the
Thrift Savings Plan) or from social security.
B. What to Show on the Form
1. HONORARIA - For you or your spouse, show
honoraria aggregating more than $200 from any one
source. Report the identity of the source in BLOCK A,
and the date of the services performed and actual
amount in BLOCK C. List each honorarium separately.
For example, if, prior to your Government service, you
received $1,500 for a speech before the Chicago Civic
Club on March 19, 1999 of which $200 was actually
spent for round-trip travel, and $200 went to the agent
who made the speaking arrangement, on your new entrant report you would enter in BLOCK A... “Chicago
Civic Club, Chicago, IL”; in BLOCK
C under OTHER (specify type)... “Honorarium”; for

ACTUAL AMOUNT... “$1,100,” and under DATE...
“3/19/99.” Honoraria received and donated to charity
must be reported, but a notation explaining that fact may
be included in reporting such items. The source, date and
amount of payments made or to be made directly to a
charitable organization in lieu of honoraria must also be
disclosed.
2. EARNED AND OTHER NON-INVESTMENT
INCOME - Include all income, exclusive of honoraria,
from non-investment sources including fees, commissions, salaries, and income from personal services or
retirement. Report the identity of the source and give
the actual amount of such income exceeding $200
from any one source. For example, if you earned $450
teaching at a law school, enter in BLOCK A... “John
Jones Law School, Rockville, MD”; in BLOCK C under
OTHER... “Salary”; and under ACTUAL AMOUNT...
“$450.” If you earned $75 for teaching in one law school
and $250 from teaching at another school, report only the
$250 amount. Report employee benefits and severance
payments which meet the reporting requirements separately from salary.
If your spouse has earned income in excess of $1,000
(other than honoraria) from any one source, identify the
source but show nothing under amount.
If your spouse
is self-employed in a business or profession, for example
as a practicing psychologist who earned $10,500 during
the year, you need only show under BLOCK A... “practicing psychologist.”
IV. Investment Income
(BLOCKS A and C)
Report items of investment income on the same line of
Schedule A as the related property interest or other asset
from which income is derived. Note that some property
interests or other assets will not have a related item
of income. In such a case, check “None (or less than
$201)” in BLOCK C under category of amount.

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A. Items to Report
Report the identity in BLOCK A and the type and value
in BLOCK C of any investment income over $200 from
any one source received by or accrued to the benefit of
you, your spouse or dependent childduring the reporting period. For purposes of determining whether you
meet the over $200 threshold from any one source, you
must aggregate all types of investment income from that
same source. For your spouse or dependent child such
income is only required to be reported if the asset source
meets the reporting threshold in section II above.
Investment income includes, but is not limited to: income derived from dealings in property, interest, rents,
royalties, dividends, capital gains; income from annuities, the investment portion of life insurance contracts,
or endowment contracts; your distributive share of partnership or joint venture income, gross business income,
and income from an interest in an estate or trust. You
need not show the actual dollar amount of dividends,
rents and royalties, interest, capital gains, or income
from qualified trusts, excepted trusts, or excepted investment funds. For these specific types of income, you need
only check the category of amount of the item reported.
For all “other investment income” as described in item 7
below, you will have to report the actual dollar amount of
income from each source, and indicate the type in the
space marked “Other Income (Specify Type & Actual
Amount)” in BLOCK C.
B. What to Show on the Form
Check all applicable classifications of income and
corresponding categories of amounts. If more than
one type of income is derived from the same asset, check
all relevant types (unless an excepted investment fund)
and categories of amount. Categories of amount may be
distinguished by using the abbreviations D, R, I and CG
in the boxes, in lieu of checks, to represent dividends,
rents/royalties, interest or capital gains.

1. DIVIDENDS - Show in BLOCK C the amount you,
your spouse or dependent childaccrued or received as
dividends from investment sources including common
and preferred securities and underlying assets of pensions and mutual funds (unless an excepted investment
fund). Identify the source of such income and check
the category of amount.For example, if cash dividends
of $950 were received for shares of common stock of
IBM, enter in BLOCK A... “IBM common” and in
BLOCK C check that dividend income was received and
check the appropriate category of amount.
2. RENTS AND ROYALTIES- Show income accrued
or received by you, your spouse or dependent childas
rental or lease payments for occupancy or use of personal
or real property in which any one of you has an interest.
In addition, show payments accrued or received from
such interests as copyrights, royalties, inventions, patents, and mineral leases or other interests. Identify the
source of such income and check the category of
amount. For example, if you received $2,000 as rental
income from an apartment building in Miami, Florida,
enter in BLOCK A...“apartment building LQ Miami, FL,”
and in BLOCK C check that rentalincome was
received and check the appropriate category
of amount.

and check the category of amount of the gain. An
example of an entry in BLOCK A might be “sale of onethird interest in 100-acre farm in Hamilton County,
Iowa” and in BLOCK C check that capital gains were
received and check the appropriate category of amount.
5. INVESTMENT FUND INCOME - Identify the
fund and the category of amount and the type(s) of
income from investment funds such as mutual or pension
funds for you, your spouse or dependent child. This
may include dividends, capital gains and interest for a
single fund or income from an excepted investment fund.
Income from each individual asset of the fund must also
be listed, unless it is an excepted investment fund, in
which case income from individual assets is not required
to be listed. See Definition of Terms above for discussion
of excepted investment funds.

6. TRUST INCOME- Report the category of amount
and the type of income accrued or received from any
trust. Whenever you are required to identify the source of
trust income, either for yourself or for a spouse or
dependent child, it is not enough simply to say “John
Jones Trust.” Generally, the investment holdings of the
trust, discussed above under “Property Interests and
Assets,” and the income derived from each holding must
be identified to the same extent as if held directly.
3. INTEREST - Identify the source and the category However, if the trust is a qualified trust or an excepted
of amount of any interest accrued or received by you, trust, in BLOCK A show only the identity of the trust
your spouse or dependent childas income from invest- including the date of creation, in BLOCK B the category
ment holdings including: bills and notes, loans, personal of the total cash value of your interest (if a qualified
savings accounts, annuity funds, bonds, and other secu- trust), next to BLOCK C check the classification of the
rities. For example, if you earned $300 in interest during trust interest as a “qualified trust” or “excepted trust,”
the calendar year on a Savings Certificate with Federal and in BLOCK C show the category of amount of income
Savings and Loan, enter in BLOCK A... “Federal Sav- attributable to you, your spouse or dependent child.
ings and Loan (Baltimore, MD)-Savings Certificate,”
and in BLOCK C check that interest income was re- 7. OTHER INVESTMENT INCOME - Report any
ceived and check the appropriate category of amount.
other items of investment income exceeding $200 and
not described above, along with the specific type and
4. CAPITAL GAINS - Report income from capital actual amount, such as gross income from business
gains realized by you, your spouse or dependent child interests, endowment or annuity contract payments, esfrom sales or exchanges of property, business interests, tate income, or a distributive share of a partnership or
partnership interests or securities. Identify the source joint business venture income. To identify the sources of
7

other investment income, either for you, your spouse, or
a dependent child, briefly characterize in BLOCK A the
nature of the business or investment interest and, when
applicable, the location: for example...“one-third
RZQHUship in a retail furniture store LQ
Chicago, IL.” In BLOCK C under OTHER, specify the
applicable type of income, for example... “distributive
share” from a partnership or “gross income” from a
proprietorship, and under ACTUAL AMOUNT the actual amount of such income which was received during
the reporting period. Where the asset is listed because of
a value of greater than $1,000 in BLOCK B, but it does
not produce more than $200 in income for the reporting
period, check “None (or less than $201)” instead of
listing the actual amount.
Schedule B
I. Part I - Transactions
A. General Instructions and Items to Report
This part is to be completed by incumbents and
termination filers only. Give a description, the date,
and the category of amount of any purchase, sale, or
exchange of any real property, stocks, bonds, commodity futures, excepted investment fund shares, and other
securities by you, your spouse or dependent child
when the amount involved in the transaction exceeded
$1,000. Also, indicate whether sales were made pursuant
to a certificate of divestiture previously issued by OGE
to permit delayed recognition of capital gain. (For more
information on certificates of divestiture, see 5 C.F.R.
Part 2634, Subpart J.) This includes reporting any sale or
exchange of an asset involving an amount exceeding
$1,000 when the sold or exchanged asset did not yield
income of more than $200 (and therefore was not reported on Schedule A), or reporting the purchase of an
asset involving an amount exceeding $1,000 but at the
end of the reporting period having a value of $1,000
or less and earning income of $200 or less during
the reporting period (and therefore not appearing on

Schedule A). The example on the form shows the proper
way to disclose Central Airlines common stock the
reporting individual purchased for $75,000 on 2/1/99.
Note that on Schedule A there is an entry for the stock as
well since it was still held at the end of the reporting
period.
You need not report a transaction involving (1) your
personal residence (unless rented out); (2) a money
market account or personal savings account; (3) an asset
of your spouse or dependent child if the asset meets the
three-part test set forth under the instructions for
Schedule A, at II.A.; (4) a holding of a “qualified blind
trust,” a “qualified diversified trust,” or an “excepted
trust”; (5) U.S. Treasury bills, notes, and bonds; (6)
transactions which occurred prior to your Federal
Government employment; or (7) transactions solely by
and between the reporting individual, spouse, or dependent child.
You will need to report any transactions made by a nonpublic business or commercial enterprise, investment
pool, or other entity in which you, your spouse or
dependent child have a direct proprietary, general partnership or other interest unless (1) the entity is an
“excepted investment fund,” or (2) the transaction is
incidental to the primary trade or business of the entity as
indicated by you on Schedule A. (See also sections V.e.
and f. of the General Instructions preceding those for
Schedule A.)
B. What to Show on the Form
Under identification of assets, identify the property or
securities involved in the purchase, sale or exchange, and
give the date of the transaction. For example, under
IDENTIFICATION OF ASSETS... “GMC common
stock”; under TYPE OF TRANSACTION... check type;
under DATE... enter date transaction occurred; under
AMOUNT OF TRANSACTION... check the category
of value of the sale price, purchase price, or exchange
value of the property involved in the transaction. You
must also indicate whether an item was sold pursuant

to a certificate of divestiture issued by the Office of
Government Ethics under 5 C.F.R. Part 2634, Subpart J,
to permit delayed recognition of capital gain.
Where multiple transactions have occurred which involve the same asset, you may list the item once, check
purchase and/or sale, and indicate... “biweekly,”
“throughout year,” or other appropriate frequency,
and the aggregate amount of the sales and purchases.
Reporting an exchange generally requires reporting two
items since one item is exchanged for another.

2. Anything received from “relatives.” The term “relatives” means an individual who is your father, mother,
son, daughter, brother, sister, uncle, aunt, great uncle,
great aunt, first cousin, nephew, niece, husband, wife,
grandfather, grandmother, grandson, granddaughter, father-in-law, mother-in-law, son-in-law, daughter-in-law,
brother-in-law, sister-in-law, stepfather, stepmother, stepson, stepdaughter, stepbrother, stepsister, half brother,
half sister, your spouse's grandfather or grandmother, or
your fiance or fiancee;
3. Bequests and other forms of inheritance;

II. Part II - Gifts, Reimbursements, and
Travel Expenses
A. General Instructions
This Part is to be completed by incumbents and
termination filers only. The Act requires you to disclose the receipt of certain gifts, in-kind travel expenses,
and travel-related cash reimbursements by you, your
spouse or dependent child from any one source other
than the U.S. Government. This reporting requirement
applies to gifts and reimbursements received by your
spouse or dependent child to the extent the gift was not
given to him or her totally independent of the relationship to you.

4. Suitable mementos of a function honoring the reporting individual;
5. Food, lodging, transportation, and entertainment
or reimbursements provided by a foreign government
within a foreign country or by the United States Government, or D.C., State or local governments;
6. Food and beverages not consumed in connection with
a gift of overnight lodging;
7. Anything given to a spouse or dependent child totally
independent of the relationship to you;
8. Gift items in the nature of communications to
your office, such as subscriptions to newspapers and
periodicals;

B. Items to Report
Report gifts received by you, your spouse or dependent
child from any one source during the reporting period
aggregating more than $such as tangible items, or
food, lodging, transportation, or entertainment; and
travel-related cash reimbursements aggregating more
than $ from any one source. A “gift” means any
payment, forbearance, advance, rendering or deposit of
money, or anything of value, unless consideration of
equal or greater value is received by the donor. In
determining which gifts and reimbursements must be
reported or aggregated, exclude these items:
1. Anything having a value of $1 or less;
8

9. Gifts of hospitality (food, lodging, entertainment) on
the donor's personal or family premises, as defined
in 5 C.F.R. Part 2634;
10. Gifts and reimbursements received during non-Federal employment periods; and
11. Reimbursements you received for political trips
which were required to be reported under section 304
of the Federal Election Campaign Act of 1971
(2 U.S.C. § 434).

C. What to Show on the Form
1. GIFTS - Report the identity of the source, a brief
description, and the value of gifts aggregating more
than $ from any one source which were received by
you, your spouse or dependent childand which do not
fall within any of the categories of exclusions enumerated above.
a. Food, Lodging, Transportation, Entertainment.
Include travel itinerary, dates, and nature of expenses
provided. To reach a more than $ aggregation, you
determine whether any one or combination of the components within this gift category received from one
source amounts to more than $ in value. For example, if you spent a weekend at a hunting lodge
owned by AmCoal Corporation, and you received
lodging fairly valued at $150, food valued at $115, and
entertainment valued at $125, the aggregate value of the
gift is $390. A gift of this nature - hospitality at a lodge
owned by a corporation rather than an individual - would
not qualify as a “personal hospitality” exclusion. To
report this gift you would show, under SOURCE ...
“AmCoal Corp., Chicago, IL”; under
BRIEF DESCRIPTION... “lodging, food, and entertainment as a guest at hunting lodge owned by AmCoal,
1/25-27/99”; and under VALUE... “$390.”
b. Other Gifts - If you and your spouse each receive a
$175 figurine from the same donor (source), the gifts
have a value of more than $ and must be reported. To
report a gift, identify the source, briefly describe the
item(s), and show the value. In the case of the figurines,
report on the form under SOURCE... “Artifact Co.,
Omaha, NE”; and under BRIEF
DESCRIPTION...“two porcelain figurines.” Under
VALUE...“$350” would be shown.
2. REIMBURSEMENTS - Report the source, a brief
description (including a travel itinerary, dates, and
the nature of expenses provided), and the value of
any cash reimbursements (except those from the United
States Government or otherwise excluded) aggregating
more than $ which you, your spouse or dependent

child received from any one source. For example, if you
were reimbursed $400 for travel and lodging expenses in
connection with a speech you made for the Denver
Realtors Association, you would report this item on the
form by showing under SOURCE...“Denver Realtors
Assoc., Denver, CO”; under BRIEF DESCRIPTION... “travel expenses for speech made in Denver: United Airlines round trip from Washington, D.C.
1/22-23/00, $275; Denver Airport Marriott, $125”; and
under VALUE... “$400” would be shown. If your spouse
made this speech and received the reimbursement totally
independent of his or her relationship to you, no information for this item need be reported.
Note: If you receive food, transportation, lodging, and
entertainment or a reimbursement of official travel expenses from a non-profit tax-exempt institution categorized by the IRS as one falling within the terms of
26 U.S.C. § 501(c)(3), you must report the name of the
organization, a brief description of the in-kind services or
the reimbursement and the value. If known, you may
also wish to note the date you received the required
written approval from your agency to accept such items.
See 5 U.S.C. § 4111 and 5 C.F.R. Part 410, Subpart E.
You do not have to report an official reimbursement
received by the agency since it will not be received by
you in your personal capacity (nor by your spouse or
dependent child). See 31 U.S.C. § 1353 (or other agency
statute) and 41 C.F.R. Chapter 304.

any liability held during the reporting period, not just at
the end of the period. If the liability was completely paid
during the period, you may also note that on the form if
you wish.
B. Items to Report
Identify and give the category of amount of the liabilities
which you, your spouse or dependent child owed to
any creditor which exceeded $10,000 at any time during
the reporting period, except:
1. a personal liability owed to a spouse or dependent
child, or to a parent, brother, sister, or child of you, your
spouse or dependent child;
2. a mortgage or home equity loan secured by real
property which is the personal residence (or a second
residence not used for producing income) of you or
your spouse;
3. a loan secured by a personal motor vehicle, household
furniture, or appliances, where the loan does not exceed
the purchase price of the item;
4. a revolving charge account where the outstanding
liability did not exceed $10,000 as of the close of the
reporting period; and

A. General Instructions

5. any liability of your spouse or dependent child which
represents the sole financial interest or responsibility of
the spouse or child, and about which you have no
knowledge, and which is not derived from your income,
assets, or activities, and concerning which you neither
derive nor expect to derive any financial or economic
benefit.

The Act requires you to disclose certain of your
financial liabilities. The examples on the form show how
to report a mortgage on real estate the reporting individual held for the production of income and a promissory note. Note that you will need to disclose the date,
interest rate and term (if applicable) of each liability.
Also note you must disclose the highest amount owed on

You are required to report any liability of any non-public
company, investment pool, or other entity, in which you,
your spouse or dependent child have an interest, unless
(1) the liability is incidental to the primary trade or
business of the entity as indicated by you on Schedule A,
or (2) the entity is an excepted investment fund. (See also

Schedule C
I. Part I - Liabilities

9

sections V.e. and f. of the General Instructions preceding
those for Schedule A.)
C. What to Show on the Form
Under CREDITORS (NAME&,7< AND S7$7(), show
the name and address of the actual creditor unless the
reporting individual is only able to identify a fiduciary
and certifies in the report that he has made a good faith
effort to determine who the actual creditor is and was
unable to do so, or upon his certification that such
determination is otherwise impracticable. Under TYPE
OF LIABILITY, briefly indicate the nature of the liability. Under DATE, enter date loan incurred; under INTEREST RATE, note the set rate or, if a variable one, the
formula used to vary the rate, i.e. prime +2%; and under
TERM, show the duration of the loan. Check the category of value for the highest amount owed during the
reporting period.
II. Part II - Agreements or Arrangements
A. General Instructions and Items to Report
Provide information regarding any agreements or
arrangements you have concerning (1) future employment; (2) a leave of absence during your period of
Government service; (3) continuation of payments by a
former employer other than the United States Government; and (4) continuing participation in an employee
welfare or benefit plan maintained by a former employer
other than United States Government retirement benefits. This includes any agreements or arrangements
with a future employer entered into by a termination
filer. The example on the form shows the severance
agreement under which the reporting individual expects
to receive a lump sum payment from the law firm he has
left in order to enter the Government. (Also note the
related asset and income reported in the second example
on Schedule A of the form.)

For purposes of public disclosure, you must disclose any
negotiations for future employment from the point you
and a potential non-Federal employer have agreed to
your future employment by that employer whether or not
you have settled all of the terms, such as salary, title,
benefits, and date employment is to begin. Your agency
may require internal disclosure of negotiations much
earlier and you should seek guidance before conducting
any negotiations with persons with whom you do business. A criminal statute, 18 U.S.C. § 208, applies to
official actions you may take while negotiating future
employment.
B. What to Show on the Form
Under STATUS AND TERMS, describe the agreement
or arrangement with appropriate specificity. Under
PARTIES, show the name of the organization, or entity,
and (if applicable) the name and title of the official,
corporate officer, or principal person responsible for
carrying out the terms of the agreement or arrangement.
Under DATE, show the date of any such arrangement.
No report is required regarding any agreement or
arrangement entered into by a spouse or dependent
child.
Schedule D
I. Part I - Outside Positions
A. Items to Report
Report all outside positions held at any time during the
reporting period, as well as those positions you currently
hold as an officer, director, trustee, general partner,
proprietor, representative, employee or consultant of (1)
any corporation, company, firm, partnership, trust, or
other business enterprise; (2) any non-profit organization; (3) any labor organization; (4) any educational
institution; or (5) any organization other than the United
States Government. Exclude positions held in any

10

religious, social, fraternal, or political entity, and any
positions solely of an honorary nature. Be sure to report
on Schedule A any income over $200 that you received
from acting in any of these positions. No report is
required regarding any positions held by your spouse
or dependent child.
B. What to Show on the Form
Give the name, address and brief description (type) of the
organization, the title or other brief functional description of the position, and the dates you held the position.
If you currently hold the position, in the entry block under
TO, note “Present.”
II. Part II - Compensation in Excess of $5,000 Paid by
One Source
A. General Instructions
This Part is to be completed by nominees and new
entrants only. You must disclose your sources of compensation in excess of $5,000 and the nature of the duties
you provided. This includes not only the source of your
salary or other fees, but the disclosure of clients for whom
you personally provided more than $5,000 in services
even though the clients' payments were made to your
employer, firm or other business affiliation. The examples on the form show the proper way to disclose the
business affiliation which paid the reporting individual's
compensation, in this case a law firm, and a client of the
firm for which the reporting individual personally provided over $5,000 worth of services. This Part does not
require you to disclose the value of the compensation for
these services; it does require a brief description of the
services you provided. When a source has paid you
directly, you should have a corresponding entry on
Schedule A if the payment was within the reporting
period for Schedule A. A client who paid your business
affiliation more than $5,000 for your services will
appear only in this Part.

B. Items to Report
Report the nature of the duties performed or services
rendered for any person (other than the United States
Government) from which compensation in excess of
$5,000 in either of the two preceding calendar years or
the present calendar year was received by you or an entity
which billed for your services (business affiliation).
Exclude: (1) information to the extent that it is considered confidential as a result of a privileged relationship
established by law, or (2) information about persons for
whom services were provided by a business affiliation of
which you were a member, partner or employee unless
you were directly involved in the provision of the services. The name of a client of a law firm is not generally
considered confidential. No report is required regarding compensation paid to your spouse or a dependent
child.
C. What to Show on the Form
Under SOURCE, give the name and address of the
person to whom services were provided, for example,
“Newark Real Estate Co. (Newark, NJ)”; and under
BRIEF DESCRIPTION, the title or other brief functional description of the services rendered, for example:
“tax matters researched for above firm while an associate
with Quinn and Ouspensky.”

Privacy Act Statement
Title I of the Ethics in Government Act of 1978, as
amended (the Act), 5 U.S.C. app. § 101 et seq., and
5 C.F.R. Part 2634 of the Office of Government Ethics
regulations require the reporting of this information. The
primary use of the information on this report is for review
by Government officials to determine compliance with
applicable Federal laws and regulations. This report may

also be disclosed upon request to any requesting person
pursuant to section 105 of the Act or as otherwise
authorized by law. You may inspect applications for
public access of your own form upon request. 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 (OMB) during legislative coordination on private relief legislation; and (6) WRWKH'HSDUWPHQWRI
-XVWLFHRULQFHUWDLQOHJDOSURFHHGLQJVZKHQWKHGLVFORV
LQJDJHQF\DQHPSOR\HHRIWKHGLVFORVLQJDJHQF\RUWKH
8QLWHG6WDWHVLVDSDUW\WROLWLJDWLRQRUKDVDQLQWHUVWLQ
WKHOLWLJDWLRQDQGWKHXVHRIVXFKUHFRUGVLVGHHPHG
UHOHYDQWDQGQHFHVVDU\WRWHOLWLJDWLRQWRUHYLHZLQJ
RIILFLDOVLQDQHZRIILFHGHSDUWPHQWRUDJHQF\ZKHQDQ
HPSOR\HHWUDQVIHUVIURPRQHFRYHUHGSRVLWLRQWRDQRWKHU
WRD0HPEHURI&RQJUHVVRUDFRQJUHVVLRQDORIILFH
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DQGRWKHUQRQ*RYHUQPHQWHPSOR\HHVZRUNLQJIRUWKH
)HGHUDO*RYHUQPHQWWRDFFRPSOLVKDIXQFWLRQUHODWHG
WRDQ2*(*RYHUQPHQWZLGHV\VWHPRIUHFRUGV.
See also the OGE/GOVT-1 executive branchwide
Privacy Act system ofrecords. Knowing and willful
falsification of information, or failure to file or report
information required to bereported by section 102 of
the Act, may subject you to acivil monetary penalty and
to disciplinary action by youremploying agency or
other appropriate authority undersection 104 of the Act.
Knowing and willful falsificationof information
required to be filed by section 102 of theAct may also
subject you to criminal prosecution.

11

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7KLVFROOHFWLRQRILQIRUPDWLRQLVHVWLPDWHGWRWDNHDQG
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UHYLHZLQJWKHLQVWUXFWLRQVJDWKHULQJWKHGDWDQHHGHG
DQGFRPSOHWLQJWKHIRUP6HQGFRPPHQWVUHJDUGLQJWKH
EXUGHQHVWLPDWHRUDQ\RWKHUDVSHFWRIWKLVFROOHFWLRQRI
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EXUGHQWRWKH$VVRFLDWH'LUHFWRUIRU$GPLQLVWUDWLRQ
8.S. Office of Government Ethics (OGE), Suite 500,
1201 New York Avenue, NW., Washington, DC 200053917. Do not file financial disclosure reports at this
address; submit them as indicated in “Where to File” on
page 3.
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, 3209-0001, is displayed here and in the upper
right-hand corner of the first page of this Standard
Form 278).

Important Note on Reporting of Higher-Value
Category Items on Schedules A, B and C
of the 2*( 278:
For assets, income, transactions and liabilities of over
$1,000,000 in value that are held solely by your spouse
or dependent children, just mark the over $1,000,000
column. For such items which you as the filer hold, either
singly or jointly with your spouse or dependent children,
you must mark the other higher categories of value, as
appropriate. For assets, transactions and liabilities, the
higher categories are $1,000,001 to $5,000,000;
$5,000,001 to $25,000,000; $25,000,001 to $50,000,000;
and over $50,000,000. For income, the higher categories
are $1,000,001 to $5,000,000; and over $5,000,000.
Asterisked notes on Schedules A, B, and C explain these
higher-value category reporting requirements.

OGE Form 278 (Rev. 09/2010)
5 C.F.R. Part 2634
U.S. Office of Government Ethics

Executive Branch Personnel PUBLIC FINANCIAL DISCLOSURE REPORT

Date of Appointment, Candidacy, Election, R e p o r t i n g
or Nomination (Month, Day, Year)

Incumbent

Status

Calendar Year
Covered by Report

(Check Appropriate
Boxes)

Reporting
Individual's Name

New Entrant,
Nominee, or
Candidate

Termination Termination Date ( If Applicable) (Month, Day, Year)
Filer

Last Name

First Name and Middle Initial

Title of Position

Department or Agency (If Applicable)

Position for Which
Filing
Location of
Present Office

Presidential Nominees Subject
to Senate Confirmation

Certification

Address (Number, Street, City, State , and ZIP Code)

Telephone No. (Include Area Code)

Title of Position(s) and Date(s) Held

Name of Congressional Committee Considering Nomination Do You Intend to Create a Qualified Diversified Trust?

Yes

No
Date (Month, Day, Year)

Signature of Reporting Individual

Agency Ethics Official's Opinion

Schedule B
B--Not applicable.
Signature of Designated Agency Ethics Official/Reviewing Official

Date (Month, Day, Year)

Signature

Date (Month, Day, Year)

S c h e d u l e C , P a r t I (Liabilities)--The
reporting period is the preceding calendar
year and the current calendar year up to
any date you choose that is within 31 days
of the date of filing.

On the basis of information contained in this
report, I conclude that the filer is in compliance
with applicable laws and regulations (subject to
any comments in the box below).

Offic
e of Governmen
ce
ntt E t h i c s
Use Only

T e r m i n a t i o n F i l e r ss: The reporting
period begins at the end of the period
covered by your previous filing and ends
at the date of termination. Part II of
Schedule D is not applicable.

Schedule A
A--The reporting period
for income (BLOCK C) is the preceding
calendar year and the current calendar
year up to the date of filing. Value assets
as of any date you choose that is within
31 days of the date of filing.

Date (Month, Day, Year)

Signature of Other Reviewer

I n c u m b e n t ss: The reporting period is
the preceding calendar year except Part
II of Schedule C and Part I of Schedule D
where you must also include the filing
year up to the date you file. Part II of
Schedule D is not applicable.

Nominees, New Entrants and
Candidates for President and
Vice President:

I CERTIFY that the statements I have
made on this form and all attached
schedules are true, complete and correct
to the best of my knowledge.
Other Review
(If desired by
agency)

Fee for Late Filing
Any individual who is required to file
this report and does so more than 30 days
after the date the report is required to be
filed, or, if an extension is granted, more
than 30 days after the last day of the
filing extension period, shall be subject
to a $200 fee.

Reporting Periods

(or forwarding address)
Position(s) Held with the Federal
Government During the Preceding
12 Months (If Not Same as Above)

Form Approved:
OMB No. 3209 - 0001

S c h e d u l e C , P a r t I I (Agreements or
Arrangements)--Show any agreements or
arrangements as of the date of filing.
S c h e d u l e D --The reporting period is
the preceding t w o calendar years and
the current calendar year up to the date
of filing.

Comments of Reviewing Officials (If additional space is required, use the reverse side of this sheet)

(Check box if filing extension granted & indicate number of days

)
Agency Use Only

OGE Use Only

(Check box if comments are continued on the reverse side)

Supersedes SF 278 Editions

OGE Form 278 (Rev. 09/2010)
5 C.F.R. Part 2634
U.S. Office of Government Ethics
Reporting Individual's Name

Valuation o f Assets
at close of reporting period
BLOCK B

Doe Jones & Smith, Hometown, State
Kempstone Equity Fund
IRA: Heartland 500 Index Fund

x

Other
Income
Over $5,000,000

$1,000,001 - $5,000,000

Over $1,000,000*
*

$15,001 - $50,000

$5,001 - $15,000

$2,501 - $5,000

$1,001 - $2,500

None (or less than $201)

$201 - $1,000

Amount

Capital Gains

Rent and Royalties

Interest

Dividends

Excepted Trust

Qualified Trust

Excepted Investment Fund

Over $50,000,000

$25,000,001 - $50,000,000

$1,000,001 - $5,000,000

$5,000,001 - $25,000,000

Over $1,000,000*
*

$500,001 - $1,000,000

$250,001 - $500,000

$100,001 - $250,000

x

Central Airlines Common

Examples

$50,001 - $100,000

$15,001 - $50,000

$1,001 - $15,000

Type
None (or less than $1,001)

None

BLOCK C

$100,001 - $1,000,000

BLOCK A

For yourself, also report the source and actual
amount of earned income exceeding $200 (other
than from the U.S. Government). For your spouse,
report the source but not the amount of earned
income of more than $1,000 (except report the
actual amount of any honoraria over $200 of
your spouse).

I n c o m e : type and amount. If “None (or less than $201)” is
checked, no other entry is needed in Block C for that item.

$50,001 - $100,000

Assets and Income

For you, your spouse, and dependent children,
report each asset held for investment or the
production of income which had a fair market
value exceeding $1,000 at the close of the reporting period, or which generated more than $200
in income during the reporting period, together
with such income.

Page Number

SCHEDULE A

(Specify
Type &
Actual
Amount)

x
Law Partnership
Income $130,000

x
x

x
x

x

x
x

1

2

3

4

5

6

* This category applies only if the asset/income is solely that of the filer's spouse or dependent children. If the asset/income is either that of the filer or jointly held
by the filer with the spouse or dependent children, mark the other higher categories of value, as appropriate.

Date
(Mo., Day,
Yr.)
Only if
Honoraria

OGE Form 278 (Rev. 09/2010)
5 C.F.R. Part 2634
U.S. Office of Government Ethics
Reporting Individual's Name

Page Number

SC
HEDULE A continued
CHEDULE
(Use only if needed)

Assets and Income

Valuation o f Assets
at close of reporting period

BLOCK A

BLOCK B

I n c o m e : type and amount. If “None (or less than $201)” is
checked, no other entry is needed in Block C for that item.
BLOCK C

Other
Income
Over $5,000,000

$1,000,001 - $5,000,000

Over $1,000,000*
*

$100,001 - $1,000,000

$15,001 - $50,000

$50,001 - $100,000

$2,501 - $5,000

$5,001 - $15,000

$1,001 - $2,500

None (or less than $201)

$201 - $1,000

Amount

Capital Gains

Interest

Dividends

Rent and Royalties

Qualified Trust

Excepted Trust

Excepted Investment Fund

Over $50,000,000

$25,000,001 - $50,000,000

$5,000,001 - $25,000,000

$1,000,001 - $5,000,000

$500,001 - $1,000,000

Over $1,000,000*
*

$100,001 - $250,000

$250,001 - $500,000

$50,001 - $100,000

$15,001 - $50,000

$1,001 - $15,000

None (or less than $1,001)

Type

1

2

3

4

5

6

7

8

9

* This category applies only if the asset/income is solely that of the filer's spouse or dependent children. If the asset/income is either that of the filer or jointly held
by the filer with the spouse or dependent children, mark the other higher categories of value, as appropriate.

(Specify
Type &
Actual
Amount)

Date
(Mo., Day,
Yr.)
Only if
Honoraria

OGE Form 278 (Rev. 09/2010)
5 C.F.R. Part 2634
U.S. Office of Government Ethics

Do not complete Schedule B if you are a new entrant, nominee, or Vice Presidential or Presidential Candidate

SCHEDULE B

Reporting Individual's Name

Page Number

Part I: Transactions
None

x

Central Airlines Common

2/1/99

x

1
2
3
4
5

* This category applies only if the underlying asset is solely that of the filer's spouse or dependent children. If the underlying asset is either held
by the filer or jointly held by the filer with the spouse or dependent children, use the other higher categories of value, as appropriate.

Part II: Gifts, Reimbursements, and Travel Expenses
For you, your spouse and dependent children, report the source, a brief description, and the value of: (1) gifts (such as tangible items, transportation, lodging,
food, or entertainment) received from one source totaling more than $335, and
(2) travel-related cash reimbursements received from one source totaling more
than $335. For conflicts analysis, it is helpful to indicate a basis for receipt, such
as personal friend, agency approval under 5 U.S.C. § 4111 or other statutory
authority, etc. For travel-related gifts and reimbursements, include travel itinerary,
dates, and the nature of expenses provided. E x c l u d e anything given to you by

Source (Name and Address)
Examples
1
2
3
4
5

the U.S. Government; given to your agency in connection with official travel;
received from relatives; received by your spouse or dependent child totally
independent of their relationship to you; or provided as personal hospitality at
the donor's residence. Also, for purposes of aggregating gifts to determine the
total value from one source, exclude items worth $134 or less. See instructions
for other exclusions.
None

Brief Description

Value

Nat'l Assn. of Rock Collectors, NY, NY

Airline ticket, hotel room & meals incident to national conference 6/15/99 (personal activity unrelated to duty)

$500

Frank Jones, San Francisco, CA

Leather briefcase (personal friend)

$350

Certificate of
divestiture

Over
$50,000,000

$25,000,001 $50,000,000

$5,000,001 $25,000,000

$1,000,001 $5,000,000

Over
*
$1,000,000*

$500,001 $1,000,000

$250,001 $500,000

$100,001 $250,000

$50,001 $100,000

Date
(Mo.,
Day, Yr.)

$15,001 $50,000

Amount of Transaction (x)

$1,001 $15,000

Exchange

Identification of Assets
Example

Transaction
Type (x)

Sale

Do not report a transaction involving
property used solely as your personal
residence, or a transaction solely between
you, your spouse, or dependent child.
Check the “Certificate of divestiture” block
to indicate sales made pursuant to a
certificate of divestiture from OGE.

Purchase

Report any purchase, sale, or exchange
by you, your spouse, or dependent
children during the reporting period of any
real property, stocks, bonds, commodity
futures, and other securities when the
amount of the transaction exceeded $1,000.
Include transactions that resulted in a loss.

OGE Form 278 (Rev. 09/2010)
5 C.F.R. Part 2634
U.S. Office of Government Ethics

Do not complete Schedule B if you are a new entrant, nominee, or Vice Presidential or Presidential Candidate

Reporting Individual's Name

Page Number

SCHEDULE B continued
(Use only if needed)

Part I: Transactions

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

* This category applies only if the underlying asset is solely that of the filer's spouse or dependent children. If the underlying asset is either held
by the filer or jointly held by the filer with the spouse or dependent children, use the other higher categories of value, as appropriate.

Certificate of
divestiture

Over
$50,000,000

$25,000,001 $50,000,000

$5,000,001 $25,000,000

$1,000,001 $5,000,000

Over
*
$1,000,000*

$500,001 $1,000,000

$250,001 $500,000

$100,001 $250,000

$50,001 $100,000

Date
(Mo.,
Day, Yr.)

$15,001 $50,000

Amount of Transaction (x)

$1,001 $15,000

Exchange

Sale

Identification of Assets

Purchase

Transaction
Type (x)

OGE Form 278 (Rev. 09/2010)
5 C.F.R. Part 2634
U.S. Office of Government Ethics
Reporting Individual's Name

Page Number

SCHEDULE C

Examples

First District Bank, Washington, DC

Mortgage on rental property, Delaware

1991

8%

25 yrs.

John Jones, Washington, DC

Promissory note

1999

10%

on demand

Over
$50,000,000

$25,000,001 $50,000,000

$5,000,001 $25,000,000

$1,000,001$5,000,000

Term if
applicable

Over
*
$1,000,000*

Interest
Rate

$500,001 $1,000,000

Date
Incurred

$250,001 $500,000

Type of Liability

Category of Amount or Value (x)

$100,001$250,000

Creditors (Name and Address)

None

$50,001 $100,000

a mortgage on your personal residence
unless it is rented out; loans secured by
automobiles, household furniture
or appliances; and liabilities owed to
certain relatives listed in instructions.
See instructions for revolving charge
accounts.

$15,001 $50,000

Report liabilities over $10,000 owed
to any one creditor at a n y t i m e
during the reporting period by you,
your spouse, or dependent children.
Check the highest amount owed
during the reporting period. E x c l u d e

$10,001 $15,000

P a r t I : Liabilities

x
x

1

2

3

4

5

* This category applies only if the liability is solely that of the filer's spouse or dependent children. If the liability is that of the filer or a joint liability of the filer
with the spouse or dependent children, mark the other higher categories, as appropriate.

Part II: Agreements or Arrangements
Report your agreements or arrangements for: (1) continuing participation in an
employee benefit plan (e.g. pension, 401k, deferred compensation); (2) continuation of payment by a former employer (including severance payments); (3) leaves

of absence; and (4) future employment. See instructions regarding the reporting of negotiations for any of these arrangements or benefits.
None

Status and Terms of any Agreement or Arrangement
Example
1
2

3

4

5

6

Pursuant to partnership agreement, will receive lump sum payment of capital account & partnership share
calculated on service performed through 1/00.

Parties
Doe Jones & Smith, Hometown, State

Date
7/85

OGE Form 278 (Rev. 09/2010)
5 C.F.R. Part 2634
U.S. Office of Government Ethics
Page Number

Reporting Individual's Name

SCHEDULE D
P a rrtt I : Position
s H e lld
d Outsid
e U.S
Positions
Outside
S.. Government
Report any positions held during the applicable reporting period, whether compensated or not. Positions include but are not limited to those of an officer, director,
trustee, general partner, proprietor, representative, employee, or consultant of
any corporation, firm, partnership, or other business enterprise or any non-profit
Organization (Name and Address)
Examples

organization or educational institution. E x c l u d e positions with religious,
social, fraternal, or political entities and those solely of an honorary
nature.
None
Position Held

Type of Organization

From (Mo., Yr.)

To (Mo.,Yr.)

Nat'l Assn. of Rock Collectors, NY, NY

Non-profit education

President

6/92

Present

Doe Jones & Smith, Hometown, State

Law firm

Partner

7/85

1/00

1

2

3

4

5

6

P a r t I I : Compensatio
n i n Excess o f $5,000 P a iid
d b y O n e Source
Compensation
Report sources of more than $5,000 compensation received by you or your
business affiliation for services provided directly by you during any one year of
the reporting period. This includes the names of clients and customers of any
corporation, firm, partnership, or other business enterprise, or any other
Source (Name and Address)
Examples
1

2

3

4

5

6

Do not complete this part if you are an
Incumbent, Termination Filer, or Vice
Presidential or Presidential Candidate.

non-profit organization when
you directly provided the
services generating a fee or payment of more than $5,000. You
need not report the U.S. Government as a source.
Brief Description of Duties

Doe Jones & Smith, Hometown, State

Legal services

Metro University (client of Doe Jones & Smith), Moneytown, State

Legal services in connection with university construction

None