Sample report from Integrity

Annual Report 2019 for Calendar Year 2018 | U.S. Office of Government Ethics; 5 C.F.R. part 2634 | Form Approved: OMB No. (3209-0001) (January 2019)

Executive Branch Personnel
Public Financial Disclosure Report (OGE Form 278e)
Filer's Information
TR_OGE_0374, testFirst mi
Deputy Secretary, November 2018 Test Agency
Report Year: 2019
Other Federal Government Positions Held During the Preceding 12 Months:
None

Electronic Signature - I certify that the statements I have made in this form are true, complete and correct to the best of my knowledge.
/s/ TR_OGE_0374, testFirst mi [electronically signed on 11/26/2018 by TR_OGE_0374, testFirst mi in Integrity.gov]

Agency Ethics Official's Opinion - 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 below).
/s/ TR_OGE_0339, testFirst mi, Certifying Official [electronically signed on 11/26/2018 by TR_OGE_0339, testFirst mi in Integrity.gov]

Other review conducted by

U.S. Office of Government Ethics Certification
/s/ TR_OGE_0794, testFirst Mi, Certifying Official [electronically signed on 11/26/2018 by TR_OGE_0794, testFirst Mi in Integrity.gov]

TR_OGE_0374, testFirst mi - Page 1

1. Filer's Positions Held Outside United States Government
#

ORGANIZATION NAME

CITY, STATE

ORGANIZATION
TYPE

POSITION HELD

FROM

TO

1

George and Chapman, LLP

New York, New
York

Law Firm

Partner

5/2011

Present

2

Widgets Unlimited, Inc.

Grand Rapids,
Michigan

Corporation

Senior Vice
President

2/2003

7/2013

VALUE

INCOME TYPE

INCOME
AMOUNT

Partnership
Share

$338,150

2. Filer's Employment Assets & Income and Retirement Accounts
#

DESCRIPTION

EIF

1

George and Chapman, LLP (law firm)

N/A

2

Widgets Unlimited Restricted Stock

See Endnote

N/A

$50,001 $100,000

None (or less
than $201)

3. Filer's Employment Agreements and Arrangements
#

EMPLOYER OR PARTY

CITY, STATE

STATUS AND TERMS

DATE

1

Geotronics Corp.

Duluth,
Minnesota

I will continue to participate in this defined benefit
plan.

3/1997

2

Widgets Unlimited, Inc.

Grand Rapids,
Michigan

I will forfeit my unvested restricted stock upon my
separation.

3/2010

3

George and Chapman, LLP

New York, New
York

Pursuant to the partnership agreement, following my
withdrawal from the firm, I will receive a lump sum
payment of my capital account. This payment will be
calculated as of the date of my resignation.

5/2011

TR_OGE_0374, testFirst mi - Page 2

4. Filer's Sources of Compensation Exceeding $5,000 in a Year
(N/A) - Not required for this type of report

5. Spouse's Employment Assets & Income and Retirement Accounts
#

DESCRIPTION

EIF

VALUE

INCOME TYPE

1

American Broadcasting Corporation

N/A

Salary

2

American Broadcasting Corporation,
defined benefit plan (value not readily
ascertainable)

N/A

Retirement
Payments

INCOME
AMOUNT

6. Other Assets and Income
#

DESCRIPTION

EIF

VALUE

1

Allianz Dividend Value Fund

Yes

None (or less
than $1,001)

$1,001 - $2,500

2

American Funds Growth Fund of Amer A

Yes

None (or less
than $1,001)

$1,001 - $2,500

3

Exxon Mobil Corp

N/A

$50,001 $100,000

4

Positron Capital, Ventures, LP (venture
capital fund)

No

$250,001 $500,000

4.1

Hydroponics Unlimited, LLC (agricultural
products)

N/A

$15,001 $50,000

See Endnote

INCOME TYPE

Dividends

INCOME
AMOUNT

$1,001 - $2,500

None (or less
than $201)

TR_OGE_0374, testFirst mi - Page 3

#

DESCRIPTION

EIF

VALUE

INCOME TYPE

INCOME
AMOUNT

4.2

Grower's Corn Syrup (Corn Syrup
Manufacturer)

N/A

$50,001 $100,000

5

Abbott Laboratories

N/A

$250,001 $500,000

Dividends

$5,001 - $15,000

6

Automatic Data Processing

N/A

$250,001 $500,000

Dividends

$5,001 - $15,000

None (or less
than $201)

7. Transactions
#

DESCRIPTION

TYPE

DATE

AMOUNT

1

Chevron Corp

Sale

6/12/18

$15,001 $50,000

2

Exxon Mobil Corp

Sale

6/12/18

$15,001 $50,000

8. Liabilities
#

CREDITOR NAME

TYPE

AMOUNT

YEAR
INCURRED

RATE

TERM

1

First District Bank

Mortgage
(investment/ren
tal property)

$100,001 $250,000

2010

4.10%

30 years

2

XYZ National Visa

Credit Card

$10,001 $15,000

2011

variable

revolving

3

John Doe

Personal Loan

$10,001 $15,000

2015

prime +1%

on demand

TR_OGE_0374, testFirst mi - Page 4

9. Gifts and Travel Reimbursements
#

SOURCE NAME

CITY, STATE

BRIEF DESCRIPTION

VALUE

1

Mary Smith

Louisville,
Kentucky

Electronic organizer (birthday present)

$480

2

Rock Collectors Association

Los Angeles,
California

Airline ticket, hotel room, and meals incident to
speech at convention in St. Louis, MO, (August 1 -2,
2018). Personal activity unrelated to official duties.

$720

Endnotes
PART

#

ENDNOTE

2.

2

Lorem ipsum dolor sit amet, consectetur adipisicing elit, sed do eiusmod tempor incididunt ut labore
et dolore magna aliqua.

6.

4.1

Lorem ipsum dolor sit amet, consectetur adipisicing elit, sed do eiusmod tempor incididunt ut labore
et dolore magna aliqua.

TR_OGE_0374, testFirst mi - Page 5

Summary of Contents
1. Filer's Positions Held Outside United States Government
Part 1 discloses positions that the filer held at any time during the reporting period (excluding positions with the United States Government). Positions are reportable
even if the filer did not receive compensation.
This section does not include the following: (1) positions with religious, social, fraternal, or political organizations; (2) positions solely of an honorary nature; (3) positions
held as part of the filer's official duties with the United States Government; (4) mere membership in an organization; and (5) passive investment interests as a limited
partner or non-managing member of a limited liability company.
2. Filer's Employment Assets & Income and Retirement Accounts
Part 2 discloses the following:
●

●

Sources of earned and other non-investment income of the filer totaling more than $200 during the reporting period (e.g., salary, fees, partnership share,
honoraria, scholarships, and prizes)
Assets related to the filer's business, employment, or other income-generating activities (1) that ended the reporting period with a value greater than $1,000 or (2)
from which more than $200 in income was received during the reporting period (e.g., equity in business or partnership, stock options, retirement plans/accounts
and their underlying holdings as appropriate, deferred compensation, and intellectual property, such as book deals and patents)

This section does not include assets or income from United States Government employment or assets that were acquired separately from the filer's business,
employment, or other income-generating activities (e.g., assets purchased through a brokerage account). Note: The type of income is not required if the amount of
income is $0 - $200 or if the asset qualifies as an excepted investment fund (EIF).
3. Filer's Employment Agreements and Arrangements
Part 3 discloses agreements or arrangements that the filer had during the reporting period with an employer or former employer (except the United States
Government), such as the following:
●
●
●
●
●

Future employment
Leave of absence
Continuing payments from an employer, including severance and payments not yet received for previous work (excluding ordinary salary from a current employer)
Continuing participation in an employee welfare, retirement, or other benefit plan, such as pensions or a deferred compensation plan
Retention or disposition of employer-awarded equity, sharing in profits or carried interests (e.g., vested and unvested stock options, restricted stock, future share of
a company's profits, etc.)

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4. Filer's Sources of Compensation Exceeding $5,000 in a Year
Part 4 discloses sources (except the United States Government) that paid more than $5,000 in a calendar year for the filer's services during any year of the reporting
period.
The filer discloses payments both from employers and from any clients to whom the filer personally provided services. The filer discloses a source even if the source
made its payment to the filer's employer and not to the filer. The filer does not disclose a client's payment to the filer's employer if the filer did not provide the services
for which the client is paying.
5. Spouse's Employment Assets & Income and Retirement Accounts
Part 5 discloses the following:
●

●
●

Sources of earned income (excluding honoraria) for the filer's spouse totaling more than $1,000 during the reporting period (e.g., salary, consulting fees, and
partnership share)
Sources of honoraria for the filer's spouse greater than $200 during the reporting period
Assets related to the filer's spouse's employment, business activities, other income-generating activities (1) that ended the reporting period with a value greater
than $1,000 or (2) from which more than $200 in income was received during the reporting period (e.g., equity in business or partnership, stock options, retirement
plans/accounts and their underlying holdings as appropriate, deferred compensation, and intellectual property, such as book deals and patents)

This section does not include assets or income from United States Government employment or assets that were acquired separately from the filer's spouse's business,
employment, or other income-generating activities (e.g., assets purchased through a brokerage account). Note: The type of income is not required if the amount of
income is $0 - $200 or if the asset qualifies as an excepted investment fund (EIF). Amounts of income are not required for a spouse's earned income (excluding
honoraria).
6. Other Assets and Income
Part 6 discloses each asset, not already reported, (1) that ended the reporting period with a value greater than $1,000 or (2) from which more than $200 in investment
income was received during the reporting period. For purposes of the value and income thresholds, the filer aggregates the filer's interests with those of the filer's
spouse and dependent children.
This section does not include the following types of assets: (1) a personal residence (unless it was rented out during the reporting period); (2) income or retirement
benefits associated with United States Government employment (e.g., Thrift Savings Plan); and (3) cash accounts (e.g., checking, savings, money market accounts) at a
single financial institution with a value of $5,000 or less (unless more than $200 in income was received). Additional exceptions apply. Note: The type of income is not
required if the amount of income is $0 - $200 or if the asset qualifies as an excepted investment fund (EIF).
7. Transactions

TR_OGE_0374, testFirst mi - Page 7

Part 7 discloses purchases, sales, or exchanges of real property or securities in excess of $1,000 made on behalf of the filer, the filer's spouse or dependent child during
reporting period.
This section does not include transactions that concern the following: (1) a personal residence, unless rented out; (2) cash accounts (e.g., checking, savings, CDs, money
market accounts) and money market mutual funds; (3) Treasury bills, bonds, and notes; and (4) holdings within a federal Thrift Savings Plan account. Additional
exceptions apply.
8. Liabilities
Part 8 discloses liabilities over $10,000 that the filer, the filer's spouse or dependent child owed at any time during the reporting period.
This section does not include the following types of liabilities: (1) mortgages on a personal residence, unless rented out (limitations apply for PAS filers); (2) loans
secured by a personal motor vehicle, household furniture, or appliances, unless the loan exceeds the item's purchase price; and (3) revolving charge accounts, such as
credit card balances, if the outstanding liability did not exceed $10,000 at the end of the reporting period. Additional exceptions apply.
9. Gifts and Travel Reimbursements
This section discloses:
●
●

Gifts totaling more than $390 that the filer, the filer's spouse, and dependent children received from any one source during the reporting period.
Travel reimbursements totaling more than $390 that the filer, the filer's spouse, and dependent children received from any one source during the reporting period.

For purposes of this section, the filer need not aggregate any gift or travel reimbursement with a value of $156 or less. Regardless of the value, this section does not
include the following items: (1) anything received from relatives; (2) anything received from the United States Government or from the District of Columbia, state, or
local governments; (3) bequests and other forms of inheritance; (4) gifts and travel reimbursements given to the filer's agency in connection with the filer's official travel;
(5) gifts of hospitality (food, lodging, entertainment) at the donor's residence or personal premises; and (6) anything received by the filer's spouse or dependent children
totally independent of their relationship to the filer. Additional exceptions apply.

TR_OGE_0374, testFirst mi - Page 8

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., as amended by the Stop Trading on Congressional Knowledge Act of 2012
(Pub. L. 112-105) (STOCK Act), and 5 C.F.R. Part 2634 of the U. S. 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 in accordance with sections 105 and 402(b)(1) 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 any requesting person, subject to the limitation contained in section
208(d)(1) of title 18, any determination granting an exemption pursuant to sections 208(b)(1) and 208(b)(3) of title 18; (2) to a Federal, State, or local law enforcement agency if
the disclosing agency becomes aware of violations or potential violations of law or regulation; (3) to another Federal agency, court or party in a court or Federal administrative
proceeding when the Government is a party or in order to comply with a judge-issued subpoena; (4) to a source when necessary to obtain information relevant to a conflict of
interest investigation or determination; (5) to the National Archives and Records Administration or the General Services Administration in records management inspections; (6) to
the Office of Management and Budget during legislative coordination on private relief legislation; (7) to the Department of Justice or in certain legal proceedings when the
disclosing agency, an employee of the disclosing agency, or the United States is a party to litigation or has an interest in the litigation and the use of such records is deemed
relevant and necessary to the litigation; (8) to reviewing officials in a new office, department or agency when an employee transfers or is detailed from one covered position to
another; (9) 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; (10) to contractors and
other non-Government employees working on a contract, service or assignment for the Federal Government when necessary to accomplish a function related to an OGE
Government-wide system of records; and (11) on the OGE Website and to any person, department or agency, any written ethics agreement filed with OGE by an individual
nominated by the President to a position requiring Senate confirmation. See also the OGE/GOVT-1 executive branch-wide Privacy Act system of records.
Public Burden Information
This collection of information is estimated to take an average of ten hours per response, including time for reviewing the instructions, gathering the data needed, and completing
the form. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the Program
Counsel, U.S. Office of Government Ethics (OGE), Suite 500, 1201 New York Avenue, NW., Washington, DC 20005-3917.
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 at the top of the first page of this OGE Form 278e).

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