OGE Form 450 EXECUTIVE BRANCH CONFIDENTIAL FINANCIAL DISCLOSURE REPOR

OGE Form 450, 5 CFR Part 2634, Subpart I
U.S. Office of Government Ethics (xxxxxx)
Expires xxxxx

CONFIDENTIAL FINANCIAL DISCLOSURE REPORT
Executive Branch

Why Must I File?

Form Approved
OMB No. 3209-0006

The duties and responsibilities of your position require you to file the Confidential Financial Disclosure Report to
avoid involvement in a real or apparent conflict of interest. The purpose of this report is to assist employees and their
agencies in avoiding conflicts between official duties and private financial interests or affiliations. The information
you provide will only be used for legitimate purposes, and will not be disclosed to any requesting person unless
authorized by law. (See the Privacy Act Statement at the bottom of this page.) Please ensure that the information you
provide is complete and accurate.

When Must I File? New Entrants: The report is due within 30 days of your assuming a position designated for filing, unless your
agency requests the report earlier or your agency grants you a filing extension.
Annual Filers: The report is due no later than February 15, unless your agency grants you a filing extension.
New Entrants:
What is the
Reporting Period? Part I – Report assets as of the date of filing, but report sources of earned income, honoraria, and other noninvestment income for the preceding 12 months.
Part II – Report liabilities as of the date of filing.
Part III – Report positions for the preceding 12 months.
Part IV – Report agreements and arrangements as of the date of filing.
Annual Filers: Report the required information for the preceding calendar year (January 1 – December 31).
What if I Have
Questions?

If you have any questions about how to complete this form, please contact your ethics official or click on Resources
for Financial Disclosure Filers, and then scroll down to Confidential Financial Disclosure Filers.

PENALTIES

Falsification of information or failure to file or report information required to be reported may subject you to disciplinary action by your
employing agency or other authority. Knowing and willful falsification of information required to be reported may also subject you to
criminal prosecution.

Privacy Act Statement
5 U.S.C. § 13109, Executive Order 12674 (as modified by Executive Order 12731), and 5 CFR Part 2634, Subpart I, of the Office of Government Ethics
(OGE) regulations require the reporting of this information. Failure to provide the requested information may result in separation or disciplinary action. 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. Additional disclosures may be made pursuant to the routine uses set forth in OGE/GOVT-2: (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 source when necessary to
obtain information relevant to a conflict of interest investigation or decision; (3) to the National Archives and Records Administration in records
management inspections; (4) to the Office of Management and Budget during legislative coordination on private relief legislation; (5) when the disclosing
agency determines that the records are arguably relevant to a proceeding before a court, grand jury, or administrative or adjudicative body, or when the
adjudicator determines the records to be relevant to the proceeding; (6) to reviewing officials in a new office, department or agency when an employee
transfers or is detailed from one covered position to another; (7) to a Member of Congress or a congressional office in response to an inquiry made on behalf
of and at the request of an individual who is the subject of the record; (8) to contractors and other non-Government employees working for the Federal
Government to accomplish a function related to this OGE Government-wide system of records; (9) to appropriate agencies, entities and persons when there
has been a suspected or confirmed breach of the system of records, the agency maintaining the records has determined that there is a risk of harm to
individuals, the agency, the Federal Government, or national security, and the disclosure is reasonably necessary to assist in connection with the agency's
efforts to respond to the suspected or confirmed breach or to prevent, minimize, or remedy such harm; and (10) to another Federal agency or Federal entity,
when the agency maintaining the record determines that information from this system of records is reasonably necessary to assist the recipient agency or
entity in responding to a suspected or confirmed breach or in preventing, minimizing, or remedying the risk of harm to individuals, the recipient agency or
entity, the Federal Government, or national security. Note: When an agency is requested to furnish such records to OGE, such a disclosure is to be
considered as made to those officers and employees of the agency which co-maintains the records who have a need for the records in the performance of
their official duties in accordance with the Ethics in Government Act and other pertinent authority conferred on OGE, pursuant to the provisions of the
Privacy Act at 5 U.S.C. § 552a(b)(1). This confidential report will not be disclosed to any requesting person unless authorized by law. See also the OGE/
GOVT-2 Executive Branch Confidential Financial Disclosure Reports Privacy Act system of records.

Public Burden Information
It is estimated that completing this form, including reviewing the instructions and gathering the data needed, takes an average of three hours. No private
citizen is required to respond to a collection of information unless it displays a currently valid OMB control number as printed in the top right-hand corner
of the first page of this form. 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, 250 E Street S.W., Suite 750, Washington, DC 20024-3249. Do not send
your completed OGE Form 450 to this address.

OGE Form 450, 5 CFR Part 2634, Subpart I
U.S. Office of Government Ethics (xxxxxx)
Expires xxxxx

Form Approved
OMB No. 3209-0006

Date Received by Agency

Page Number

CONFIDENTIAL FINANCIAL DISCLOSURE REPORT
Executive Branch

E-mail Address

Employee's Name (Print last, first, middle initial )
Position/Title

Grade
Branch/Unit and Address

Agency
Work Phone
Check box if a Special
Government Employee (SGE)

Reporting Status
New Entrant

Annual

If New Entrant, Date of Appointment to Position
(mm/dd/yy)

Non-temporary full-time employees are not SGEs. An SGE is an officer or employee who
performs temporary duties, with or without compensation, for a period of less than 131 days
in any 365 day period.

Step 1: Read the instructions for Parts I through V on the following pages.
Step 2: For each statement below, check Yes or No to describe your situation.
I.a. I have reportable assets or sources of income for myself, my spouse, or my dependent children.
I.b. I have a spouse who has paid employment outside the Federal Government.
II. I have reportable liabilities (debts) for myself, my spouse, or my dependent children.
III. I have reportable outside positions for myself.
IV. I have reportable agreements or arrangements for myself.

Yes
Yes
Yes
Yes
Yes

No
No
No
No
No

NOTE: Statement V is for annual filers only. It does not apply to new entrants and SGEs.
V. I have reportable gifts or travel reimbursements for myself, my spouse, or my dependent children.

Yes

No

Step 3: If you selected Yes for any statement, you must describe the reportable interests that you have in the corresponding Part
(I, II, III, IV, or V) of the form.
Step 4: Sign and date the form.
Step 5: Submit the completed form to your ethics office.
I certify that the statements I have made on this form and all attached statements are true, complete, and correct to
the best of my knowledge.
Date (mm/dd/yy )
Signature of Employee

FOR REVIEWERS’ USE ONLY:
On the basis of information contained in this report, I conclude that the filer is in compliance with the applicable laws and
regulations, except as noted in the "comments" box below.
Signature and Title of Supervisor/Other Intermediate Reviewer (if required by the agency )
Date (mm/dd/yy )
E-mail Address
Signature and Title of Agency’s Final Reviewing Official

Phone Number
Date (mm/dd/yy )

Comments of Reviewing Officials

(Check box if continued on additional page )

OGE Form 450, 5 CFR Part 2634, Subpart I
U.S. Office of Government Ethics (xxxxxx)
Expires xxxxx
Employee’s Name (Print last, first, middle initial)

Report for Yourself, Spouse, and Dependent Child:

Form Approved
OMB No. 3209-0006
Page Number

Part I: Assets and Income

Do Not Report:
• Assets held for investment or the production of income that ended • Diversified mutual funds, such as ABC Equity Value Fund or XYZ
the reporting period with a value greater than $1,000. In addition,
Large Capital Fund
annual filers must report assets from which more than $1,000 in
• Federal Government retirement benefits
income was received during the reporting period. Reportable assets
• Thrift Savings Plan
include, but are not limited to:
• Certificates of deposit, savings or checking accounts
- Assets, such as stocks, bonds, annuities, trust holdings, partnership • Term life insurance
interests, life insurance, investment real estate, and privately held
• Money market mutual funds and money market accounts
trades or businesses
• Your personal residence, unless you rent it out
- Sector mutual funds: those funds invested in a particular industry,
• U.S. Treasury bonds, bills, notes, and savings bonds
business, or location, such as ABC Financial Fund, XYZ Energy
• Diversified funds within an employee benefit plan
Fund, or AVC Healthcare Fund (report the full name of the sector
• Money owed to you, your spouse, or dependent child by a spouse,
fund, not just the family fund name)
parent, sibling, or child
- Holdings of retirement plans, such as 401(k)s, IRAs, and variable
annuities (report each holding unless listed in the Do Not Report
Do not report account or Social Security numbers or names of
section)
family members
- Defined benefit pension plans provided by a former non-Federal
employer (include the name of the employer)
Also Report:
Do Not Report:
• For yourself: (1) all sources of salary, fees, commissions, and other • Dependent child’s earned income (e.g., wages, fees)
earned income greater than $1,000, (2) honoraria greater than $1,000, • Veterans' benefits
and (3) other non-investment income, such as scholarships, prizes,
• Federal Government salary
and gambling income greater than $1,000
• Social Security benefits
• For your spouse: (1) all sources of salary, fees, commissions, and
other earned income greater than $1,000, and (2) honoraria greater
than $1,000
Dependent Child – A son, daughter, stepson, or stepdaughter who is either unmarried, under age 21, and living in the filer’s house,
or considered dependent under the U.S. tax code.
Reportable Information
Report the full name of each individual asset, such as a stock, bond, or sector mutual fund. (You may add the
ticker symbol to the asset name.) This includes any asset that is an underlying holding of a trust, retirement, or
investment account that meets the reporting requirement. Report the type and location of any investment real estate.
Report name of employer or business, source of fees, commissions, or honoraria. (Include a brief description.)
You may distinguish any entry for a family member by preceding it with (S) for spouse or (DC) for dependent child.
EXAMPLES — Go to the last page to see additional examples of how to report assets and income.
OGC Widgets, Inc. (OGC) (Example of a stock with a ticker symbol )
(S) Express Medical Clinic — salary (Example of spouse's earned income from a current employer)
ABC Healthcare Fund (Example of a sector fund held in a 401(k) plan, IRA, or brokerage account )
XYZ 401(k) Plan (Alternative example of a sector fund in a 401(k), or other retirement or brokerage account )
- XYZ Energy Fund
- Rock Financial Fund
CA (ScholarShare) College Savings Plan: Age 0-5 Portfolio (Example of a 529 college savings plan with underlying investment)

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No longer held

OGE Form 450, 5 CFR Part 2634, Subpart I
U.S. Office of Government Ethics (xxxxxx)
Expires xxxxx
Employee’s Name (Print last, first, middle initial)

Form Approved
OMB No. 3209-0006
Page Number

Part I: Assets and Income
Continuation Page
Report the full name of each individual asset, such as a stock, bond, or sector mutual fund. (You may add the ticker
symbol to the asset name.) This includes any asset that is an underlying holding of a trust, retirement, or investment
account that meets the reporting requirement. Report the type and location of any investment real estate.
Report name of employer or business, source of fees, commissions, or honoraria. (Include a brief description.) You
may distinguish any entry for a family member by preceding it with (S) for spouse or (DC) for dependent child.

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OGE Form 450, 5 CFR Part 2634, Subpart I
U.S. Office of Government Ethics (xxxxxx)
Expires xxxxx
Employee’s Name (Print last, first, middle initial)

Form Approved
OMB No. 3209-0006
Page Number

Part I: Assets and Income
Continuation Page
Report the full name of each individual asset, such as a stock, bond, or sector mutual fund. (You may add the ticker
symbol to the asset name.) This includes any asset that is an underlying holding of a trust, retirement, or investment
account that meets the reporting requirement. Report the type and location of any investment real estate.
Report name of employer or business, source of fees, commissions, or honoraria. (Include a brief description.) You
may distinguish any entry for a family member by preceding it with (S) for spouse or (DC) for dependent child.

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OGE Form 450, 5 CFR Part 2634, Subpart I
U.S. Office of Government Ethics (xxxxxx)
Expires xxxxx
Employee’s Name (Print last, first, middle initial)

Form Approved
OMB No. 3209-0006
Page Number

Part I: Assets and Income
Continuation Page
Report the full name of each individual asset, such as a stock, bond, or sector mutual fund. (You may add the ticker
symbol to the asset name.) This includes any asset that is an underlying holding of a trust, retirement, or investment
account that meets the reporting requirement. Report the type and location of any investment real estate.
Report name of employer or business, source of fees, commissions, or honoraria. (Include a brief description.) You
may distinguish any entry for a family member by preceding it with (S) for spouse or (DC) for dependent child.

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OGE Form 450, 5 CFR Part 2634, Subpart I
U.S. Office of Government Ethics (xxxxxx)
Expires xxxxx
Employee’s Name (Print last, first, middle initial)

Report for Yourself, Spouse, and Dependent Child:

Form Approved
OMB No. 3209-0006
Page Number

Part II: Liabilities

Do Not Report:
• If you are a new entrant filer, liabilities that exceeded • Any liability, such as a mortgage, a student loan, or a credit card account, from a
financial institution or business entity granted on terms made available to the general
$10,000 at the end of the reporting period
public
• If you are an annual filer, liabilities that exceeded
• Loans secured by automobiles, household furniture, or appliances, unless the loan
$10,000 during the reporting period
exceeds the purchase price of the item it secures
• Liabilities that you owe to your spouse or to the parent, sibling, or child of you,
your spouse, or your dependent child

Reportable Information
Name of creditor (include city and state
Type of liability (personal loan, margin account, etc.)
where the creditor is located )
EXAMPLES — Go to the last page to see additional examples of how to report liabilities.
Miguel Reyes, Arlington, VA

Personal loan from a friend

ANW Financial Corp., Washington, DC

Margin account

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OGE Form 450, 5 CFR Part 2634, Subpart I
U.S. Office of Government Ethics (xxxxxx)
Expires xxxxx
Employee’s Name (Print last, first, middle initial)

Report for Yourself:

Form Approved
OMB No. 3209-0006
Page Number

Part III: Outside Positions

• All positions outside the Federal Government held at any time during the reporting
period, whether or not you were compensated and whether or not you currently hold that
position. Positions include an officer, director, employee, trustee, general partner,
proprietor, representative, executor, or consultant of any of the following:
- Corporation, partnership, or other business entity
- Trust
- Non-profit or volunteer organization
- Educational institution
- State or local government

Do Not Report:
• Any position with a
- Religious entity
- Social entity
- Fraternal entity
- Political entity
• Any position held by your spouse or dependent
child
• Any position that you hold as part of your official
duties

Reportable Information
Organization
(include city and state where the organization
is located)

Type of organization

Position

EXAMPLES — Go to the last page to see additional examples of how to report outside positions.
Brigadoon University, Highland, NY

Educational Institution

Professor

ISK Family Trust, Boynton Beach, FL

Family Trust

Trustee

Scenic Rivers Association, Nashville, TN

Non-profit Environmental

Member, Board of Directors

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No longer held

OGE Form 450, 5 CFR Part 2634, Subpart I
U.S. Office of Government Ethics (xxxxxx)
Expires xxxxx
Employee’s Name (Print last, first, middle initial)

Form Approved
OMB No. 3209-0006
Page Number

Part III: Outside Positions Continuation Page
Organization (include city and state where
the organization is located)
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OGE Form 450, 5 CFR Part 2634, Subpart I
U.S. Office of Government Ethics (xxxxxx)
Expires xxxxx
Employee’s Name (Print last, first, middle initial)

Form Approved
OMB No. 3209-0006
Page Number

Part IV: Agreements or Arrangements

Report Your Agreements or Arrangements for:

• Continuing participation in an employee pension or benefit plan maintained by a current
or former employer
• A leave of absence
• Future employment, including the date you accepted an employment offer
• Continuation of payment by a current or former employer (including severance
payments)

Do Not Report:
• Any agreement or arrangement related to your
employment by the Federal Government
• Spouse’s and dependent child’s agreements or
arrangements
• Continuing participation in a defined contribution
plan, such as a 401(k) plan, to which an employer is
no longer making contributions

Reportable Information
Entity with which you have an agreement or
arrangement (include city and state where the
entity is located)

Terms of Agreement or Arrangement

EXAMPLES — Go to the last page to see additional examples of how to report agreements and arrangements.
Dee, Jones & Smith, San Diego, CA

I will continue to participate in this defined benefit plan.

Brigadoon University, Highland, NY

I am on an unpaid leave of absence for two years.

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OGE Form 450, 5 CFR Part 2634, Subpart I
U.S. Office of Government Ethics (xxxxxx)
Expires xxxxx
Employee’s Name (Print last, first, middle initial)

Form Approved
OMB No. 3209-0006
Page Number

Part V: Gifts and Travel Reimbursements

Fill out this part only if you are filing an Annual Report. If you are a new entrant or an SGE, skip this part.
Report for Yourself, Spouse, and Dependent Child:
Do Not Report:
• Any gifts or travel reimbursements (items such as lodging, transportation, and food)
totaling more than $480* from any one source during the reporting period; include
where you traveled, the purpose, and date(s) of the trip for travel gifts and
reimbursements
*If you received more than one gift from one source:
1. Determine the value of each item you received from that source
2. Ignore each item valued at $192 or less
3. Add the value of those items valued at more than $192; if the total is more than
$480, then you must list those items on this form
NOTE: These amounts apply to gifts and travel reimbursements received in calendar
years 2023–2025. The next three–year adjustment to these amounts is scheduled to
occur in 2026.

• Anything received from relatives, the Federal
Government, DC, state, or local governments
• Bequests and other forms of inheritance
• Gifts and travel reimbursements given to your
agency in connection with your official travel
• Gifts of hospitality (food, lodging,
entertainment) at the donor’s residence or
personal premises
• Anything received by your spouse or dependent
child totally independent of their relationship to
you

Reportable Information
Source
Description
EXAMPLES — Go to the last page to see additional examples of how to report gifts and travel reimbursements.
Dee, Jones & Smith, San Diego, CA

Leather briefcase (Example of gift totaling more than $480 from one source)

CGH Culinary Institute, Tokyo, Japan

Airline ticket, hotel room, and meals incident to culinary seminar in Tokyo, Japan from
May 1-5, 2023 (Example of travel reimbursement)

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OGE Form 450, 5 CFR Part 2634, Subpart I
U.S. Office of Government Ethics (xxxxxx)
Expires xxxxx

Part I: Assets and Income

Form Approved
OMB No. 3209-0006

EXAMPLES

Report the full name of each individual asset, such as a stock, bond, or sector mutual fund. (You may add the ticker
symbol to the asset name.) This includes any asset that is an underlying holding of a trust, retirement, or investment
account that meets the reporting requirement. Report the type and location of any investment real estate.
Report name of employer or business, source of fees, commissions, or honoraria. (Include a brief description.) You
may distinguish any entry for a family member by preceding it with (S) for spouse or (DC) for dependent child.

OGC Communications (OGC) (Example of a stock with a ticker symbol)
OGE Energy (Example of sold stock that produced more than $1,000 in income that is no longer held)
Maryland Prepaid College Trust (MPCT), University Plan — 4 Years (Example of a 529 prepaid tuition plan)

No longer held

X

(S) OGE Energy bond (Example of a corporate bond held by a spouse )
ABC Healthcare Fund (Example of a sector fund held in a 401(k) plan, IRA, or brokerage account)
Residential real estate, Anchorage, AK (Example of investment real estate)
Brigadoon University — salary (Example of earned income from a former employer)
Widgets Unlimited, unvested restricted stock units (Example of an unvested restricted stock unit from a current employer)
Association of Accountants — honorarium (Example of a single honorarium from the listed source)

Part II: Liabilities
Name of creditor (include the city and state where
the creditor is located)

Type of liability (personal loan, margin account, etc.)

Jones Capital Venture, LLC, Rockville, MD

Capital commitment

Part III: Outside Positions
Organization (city and state )

Type of organization

Position

George & Chapman, LLP, Washington, DC

Law Firm

Partner

Bestever Elementary School, Buffalo, NY

Parent Teacher Association

President

Sunnydale Homeowners Association, Stowe,VT

Homeowners Association

Vice President

No longer held
X
X

Part IV: Agreements or Arrangements
Entity with which you have an agreement or
arrangement (include city and state where the
entity is located)
John Smith, Esq., Park City, UT
Allied Business Computing, Inc., Reston, VA
Icebox Repair Company, Stowe, VT
GottaGoNow Company, Fort Wayne, IN

Terms of Agreement or Arrangement
My solo legal practice will be inactive during my appointment, and all
outstanding client fees will be fixed before I enter Federal Government service.
Pursuant to company policy for retired corporate officers, my spouse and I
will retain health insurance coverage for life.
I will retain my vested restricted stock units.
Pursuant to my employment agreement, I will receive a lump sum severance payment
within 90 days of my separation from the company.

Part V: Gifts and Travel Reimbursements
Source

Description

Jane Smith

iPad, birthday gift from a friend
Helicopter ride over the Grand Canyon

Epic Views, Grand Canyon, CO