TVA 17423A Section 26a Permit and Land Use Application: Applicant D

TVA RESTRICTED INFORMATION

OMB No. 3316-0060

Exp. Date xx/xx/20xx

Section 26a Permit and Land Use Application

Applicant Disclosure Form

By signing the Joint Application Form (Department of Army/TVA) or TVA’s Land Use Application and again below, you agree to disclose any business, political, or financial interest that may present an actual or potential conflict of interest with TVA. If a new significant business, political, or financial interest is obtained during the period of the time that the application is under review, you agree to file an additional disclosure.

Disclose if any of the following apply to you (check all that apply  ). I am:

An elected government official or a candidate to an elected government office (whether federal, state, or local).

A senior management level employee of an entity that regulates TVA or its activities.

A senior management level employee of a power customer of TVA.

A current TVA employee or Director.

A former TVA officer or former TVA Director and it is less than one year after my last date of service with TVA.

A current member of a TVA council created pursuant to the Federal Advisory Committee Act (FACA), such as the Regional Resource Stewardship Council (RRSC) or Regional Energy Resource Council (RERC), or I am a former council member and it is less than one year after my last date of service on the council.

The spouse or dependent child of any of the above. List which one of the above applies.
__________________________________________________________________________

A representative of a corporation or other non-governmental entity submitting an application and one of the above applies to me. Print entity or corporation name, and identify which of the above applies to you.

     

     

A representative of a corporation or other non-governmental entity submitting an application and I have significant financial interest in the corporation or non-governmental entity. Print entity or corporation name.

     

     

     

None of the above

Please sign and return this form with your application package. Your application cannot be processed without receipt of this signed form.

By signing this form, you consent to this Applicant Disclosure Form being made available to the public in response to an appropriate request, including, without limitation, a request made under the Freedom of Information Act. All applications and communications that occur as part of the application process may be made public to the extent permitted by applicable law, including the Freedom of Information Act and the Privacy Act, and could be reviewed formally by the Office of Inspector General (OIG). All written correspondence regarding your request may be forwarded to the TVA Designated Agency Ethics Official (DAEO) and the OIG, and all oral communication between TVA and the applicant regarding this request may be documented and maintained by TVA.

     				     
Name of Applicant (Printed)		Signature of Applicant		Date

18 U.S.C. Section 1001 provides that: Whoever, in any manner within the jurisdiction of any department or agency of The United States knowingly and willfully falsifies, conceals, or covers up by any trick, scheme, or device a material fact or makes any false, fictitious or fraudulent statements or representations or makes or uses any false writing or document knowing same to contain any false, fictitious or fraudulent statement or entry, shall be fined not more than $10,000 or imprisoned not more than five years, or both.

Privacy Act Statement

This information is being requested in accordance with Sections 4(k), 15d, 26a, and/or 31 of the TVA Act; 40 U.S.C. § 1314; 30 U.S.C. § 185; 16 U.S.C. § 667b; and/or 40 U.S.C. § 483. Disclosure of the information requested is voluntary; however, failure to provide any required information or documents may result in a delay in processing your application or in your application being denied. An application that is not complete will be returned for additional information. TVA uses this information to assess the impact of the proposed project on TVA programs and the environment and to determine if the project can be approved. Information in the application is made a matter of public record through issuance of a public notice if warranted. Routine uses of this information include providing to federal, state, or local agencies, and to consultants, contractors, etc., for use in program evaluations, studies, or other matters involving support services to the program; to respond to a congressional inquiry concerning the application or the applicable program; and for oversight or similar purposes, corrective action, litigation, or law enforcement.

Burden Estimate Statement

Public reporting burden for this collection of information is estimated to average 5 minutes 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 this burden to Agency Clearance Officer, Tennessee Valley Authority, 1101 Market Street, Chattanooga, Tennessee 37402; and to the Office of Management and Budget, Paperwork Reduction Project (3316-0060), Washington, D.C. 20503.

TVA 17423A [11-01-2017] TVA RESTRICTED INFORMATION