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

Form Approved: OMB No. 3209-0007
(Revised 8/2016)

U.S. OFFICE OF GOVERNMENT ETHICS
Model Confidentiality Agreement Provisions
[For use in the case of a privately owned business]

The model confidentiality agreement contained in this memorandum is made available by
the U.S. Office of Government Ethics to attorneys for their use in drafting proposed
confidentiality agreements in those cases where such an instrument is an appropriate component
of a qualified trust arrangement submitted for certification pursuant to section 102(f)(3) or (4)(B)
of the Ethics in Government Act of 1978 (Pub. L. 95-521, as amended) and subpart D of
5 C.F.R. Part 2634. Under the statutory scheme, a trust agreement is not permitted to be
recognized as creating an efficacious blind trust arrangement for any purpose under Federal law
unless it had been certified by the Office prior to its execution. Proposed confidentiality
agreement drafts submitted to the Office for consideration must adhere to the language of the
model except to the extent, as agreed to by the U.S. Office of Government Ethics, that variations
are required by the unusual circumstances of a particular case. The fiduciaries’ certificates of
independence must be executed in the exact form indicated.

It is strongly recommended in any case in which the use of a blind trust is contemplated
that the Office be consulted as early as possible. Prospective trustees or their representatives
should schedule an appointment with the staff of the U.S. Office of Government Ethics for an
orientation to the specialized procedures and requirements which have been established by law
with respect to blind trust administration prior to the certification of the trust. As a condition of
approval by the Office, prospective trustees must exhibit a familiarity with and commitment to
the specialized nature of blind trust administration.

For further information, contact the U.S. Office of Government Ethics directly:
telephone 202-482-9300, fax 202-482-9237.

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CONFIDENTIALITY AGREEMENT

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[INSERT DATE]

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General Counsel and
Legal Policy Division
U.S. Office of Government Ethics
1201 New York Avenue NW.
Washington DC 20005-3917

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To Whom It May Concern:

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I understand that ____________ [appointee] will be appointed to the position of

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_______________ of the _______________________ [department or agency]. I further

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understand that, to avoid any conflict of interest, or appearance of any such conflict, that may

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arise from his duties and powers in such office and any other office to which he may

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subsequently be appointed, ___________ [appointee] has submitted a proposed blind trust

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arrangement to the U.S. Office of Government Ethics, and that _________ [financial

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institution] will serve as the Independent Trustee of the blind trust.

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Under the provisions of applicable law and the blind trust instrument, _____________

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[appointee], as well as his spouse, any minor or dependent child, and any of their personal and

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professional representatives, is precluded from learning any information with respect to

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__________ [private business]. Such information is called “prohibited communications” in this

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agreement. I am considered to be in possession of such information because of my interests in,

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responsibilities for, or activities with respect to __________ [private business].

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Accordingly, in order to assist __________ [appointee] in complying with applicable

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law, I agree not to have any prohibited communications with ________ [appointee], or his

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spouse and children or any of their personal and professional representatives, while the blind

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trust arrangement is inexistence. Specifically, I will not knowingly and willfully, or negligently,

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disclose or make available to any person referred to in the preceding sentence, or the media or

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general public, any information with respect to any matter involving or affecting __________

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[private business], including its sources of income and the issuance, acquisition, retention, or

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disposition of any securities or debt obligations issued, incurred, or contemplated. Also, I will

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not consult with nor advise __________ [appointee], his spouse, any minor or dependent child,

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or any of their personal and professional representatives, with respect to any matter related to

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__________ [private business]. Further, I will instruct my spouse, any minor or dependent

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child, and our representatives to restrict their communications in the manner described in this

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paragraph.

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Sincerely,

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_______________

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NOTARIZATION

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REQUIRED

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ACKNOWLEDGMENT:

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The above Confidentiality Agreement is acknowledged this ________ day of ______________,

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____.

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________________

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[appointee]

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NOTARIZATION

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REQUIRED

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The above Confidentiality Agreement is acknowledged this ________ day of ______________,

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____.

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________________

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[financial institution]

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By:____________

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(title)

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NOTARIZATION

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REQUIRED

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

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8) To disclose information to a Member of Congress or a congressional office in response to
an inquiry made on behalf of an individual who is the subject of the record.
9) To disclose the information to contractors, grantees, experts, consultants, detailees, and
other non-Government employees performing or working on a contract, service, or other
assignment for the Federal Government, when necessary to accomplish an agency
function related to this system of records.
For additional information please see OGE/GOVT-1 Governmentwide Privacy System of
Records.

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

Public Burden Information and Paperwork Reduction Statement
This collection of information is estimated to take an average of 20 minutes per
communication letter, given the estimated amount of time deemed necessary to prepare a
communication. You can send comments regarding the burden estimate or any other aspect of
this collection of information, including suggestions for reducing this burden, to: Program
Counsel, U.S. Office of Government Ethics, Suite 500, 1201 New York Avenue, NW.,
Washington, DC 20005-3917. Do not send your completed communication letter to this address;
rather, see the remainder of the instructions to this model set of drafts.
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, 3209-0007, is displayed here and in the upper
right-hand corner of the first page of this OGE model qualified trust draft document).