Form SD Form X682 SD Form X682 Office of the Secretary of Defense (OSD) Confidential Co

OFFICE OF THE SECRETARY OF DEFENSE (OSD)

DATE RECEIVED BY AGENCY

OMB No.
OMB approval expires

CONFIDENTIAL CONFLICT-OF-INTEREST STATEMENT
FOR ADVISORY COMMITTEE MEMBERS

The public reporting burden for this collection of information is estimated to average one hour per response, including the time for reviewing instructions, searching existing data sources, gathering and
maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including
suggestions for reducing the burden, to the Department of Defense, Washington Headquarters Services, Executive Services Directorate, Directives Division, 4800 Mark Center Drive, Alexandria, VA 22350-3100
(XXXX-XXXX). Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a
currently valid OMB control number.

PLEASE DO NOT RETURN YOUR FORM TO THE ABOVE ADDRESS. RETURN COMPLETED FORM TO

PRIVACY ACT STATEMENT
AUTHORITY: 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.
PRINCIPAL PURPOSE(S): 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. Completed forms are covered by Office of Government Ethics System of
Records Notice OGE/GOVT-2, Executive Branch Confidential Financial Disclosure Reports
(http://dpclo.defense.gov/Privacy/SORNsIndex/GovernmentwideArticleView/tabid/7488/Article/6897/ogegovt-2.aspx).
ROUTINE USE(S): 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 OGE Government wide system of records. This confidential report
will not be disclosed to any requesting person unless authorized by law.
DISCLOSURE: Voluntary. However, failure to file this form will preclude your service on the advisory committee. Knowing and willful falsification
of information required to be reported could subject you to criminal prosecution.
1. NAME OF ADVISORY COMMITTEE

D R A F T

2. MEMBER INFORMATION (Specify whether contact information is home or work)
a. NAME (Last, First, Middle Initial)

c. TELEPHONE (Include Area Code)

b. ADDRESS (Include ZIP Code)

d. EMAIL

In carrying out your duties as a member of an OSD advisory committee, you will be called upon to give advice on Department of Defense (DoD) policy
deliberations. We do not anticipate that you will ordinarily participate in any "particular matters." However, sometimes policy deliberations may focus
on the interests of specific persons or organizations or on a discrete and identifiable class of persons or entities. In such cases, your personal financial
interest or your affiliations or relationships with other affected persons or entities may raise conflict-of-interest questions. By providing the information
requested on this form, you will satisfy a Federal regulatory requirement and help DoD personnel identify and resolve potential conflicts. Please return
your completed statement to your Committee's Designated Federal Officer prior to participating in Committee activity. For each of the three parts below,
list all interests, positions, arrangements, or relationships that are responsive. If you have none, mark (X) the "NONE" box. If you have additional items
to report, please include them on additional pages.
PART I - FINANCIAL INTERESTS

(If none, X:)

NONE

If you, your spouse, or your dependent children receive any income (compensation, honoraria, royalties, etc.) from, or hold any stock, securities, or
similar financial interests in any nongovernmental entitiy that either is the focus of, or is a member of a discrete and identifiable class that is the focus of,
DoD policy deliberations likely to come before the Committee - list all such interests.
EXAMPLE: Report your spouse's stock in a company/contractor that could be affected by a finding/recommendation of the Advisory Committee.
IDENTIFY SPECIFIC ENTITY, AND THE NATURE OF THE INTEREST (Salary, stock, bond, etc.):

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PART II - POSITIONS AND ARRANGEMENTS

NONE

(If none, X:)

If any entity with which (1) you are now "connected", (2) you are negotiating to become "connected", or (3) you have an arrangement to become
"connected" in the future is the focus of, or is a member of a discrete and identifiable class that is the focus of, DoD policy deliberations likely to come
before the Committee - describe all such interests. You are "connected" with any entity if you serve as an employee, officer, director, trustee,
general partner, agent, attorney, consultant, or contractor for that entity.
EXAMPLES: (1) Are you connected with a corporation, professional association, university, or national laboratory that has a direct grant, cooperative
agreement or other financial relationship with DoD or parties that may be affected by recommendations of the Committee (i.e., recommendation for
current or future funding, closure of facilities, or selection of one type of research over another, etc.)? If so, name the entity and provide identifying
information on the contract, grant, cooperative agreement, or other financial relationship involved.
(2) Are you an officer in a professional association that has directly negotiated with DoD on an issue the Committee is likely to discuss? If so, name the
association and the issue involved.
IDENTIFY SPECIFIC ORGANIZATION OR
ENTITY

TYPE OF POSITION, ARRANGEMENT, OR
OTHER CONNECTION

INTEREST OR ISSUE INVOLVED

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D R A F T

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PART III - OTHER INTERESTS OR RELATIONSHIPS

(If none, X:)

NONE

Are you aware of any other current or recent interests, affiliations, or relationships, including those of your relatives with whom you have a close personal
relationship, that are either parties to or have interests that could be affected by, any policy deliberations likely to come before the Committee, or that you
believe could impair your impartiality, or that could cause a reasonable person with knowledge of the relevant facts to question your impartiality?
If so, describe all such interests.
EXAMPLE: Does your sibling's business stand to benefit by a change in DoD's administration of the program on which your committee is advising?
If so, briefly describe.
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If your designation as an advisory committee member gives you access to information not generally available to the public, you must not use that
information for your personal benefit or make it available for the personal benefit of any other individual or organization. This is different from the
entirely appropriate general benefit of learning more about DoD programs, learning from other advisory committee members, or becoming better
acquainted with the state of a given discipline.
COMMITTEE MEMBER'S CERTIFICATION
I certify that my answers to the above questions are true and complete to the best of my knowledge. I also understand that I must contact the DoD
Designated Federal Officer responsible for the Committee if a conflict exists or arises during my term of service. I also will not divulge any classified or
privileged information I may become aware of during my term.
1. MEMBER'S PRINTED NAME (Last, First, Middle Initial)

2. SIGNATURE

3. DATE (YYYYMMDD)

CERTIFICATION BY RESPONSIBLE DOD OFFICIAL
Based on my review of this form, I certify that:
No conflicts identified.
Waiver will be sought by separate document pursuant to 18 USC Section 208(b)(3) because the need for the individual's services outweighs the
potential for a conflict of interest created by the financial interest involved.
Other actions taken (explain):
1. SUPERVISOR SIGNATURE

2. DATE (YYYYMMDD)

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3. FINAL REVIEW SIGNATURE

4. DATE (YYYYMMDD)