FGIS-100 Conflict of Interest Questionnaire

Reporting and Recordkeeping Requirements (US Grain Standards Act and Agricultural Marketing Act of 1946)

FGIS 100 3.25

OMB: 0581-0309

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UNITED STATES DEPARTMENT OF AGRICULTURE
AGRICULTURAL MARKETING SERVICE
FEDERAL GRAIN INSPECTION SERVICE
COMPLIANCE DIVISION

CONFLICT OF INTEREST QUESTIONNAIRE
(NON-LICENSED OFFICIAL AGENCY PERSONNEL)

FORM APPROVED OMB NO. 0581-0309
According to the Paperwork Reduction Act of 1995, an agency
may not conduct or sponsor, and a person is not required to
respond to a collection of information unless it displays a valid
OMB control number. The valid OMB control number for this
information collection package is 0581-0309. The time required
to complete this information collection 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.

1. Full Legal Name (Print) (First, Middle, Last, Suffix)
2. Official Agency

Check if agency personnel does not
have a middle name or initial.

3. Position or Relationship to Official Agency

Please indicate your answer to each of the following questions by entering an “X” in the appropriate space. If your answer to any
questions is “YES”, or if you desire to elaborate on any of your answers, please describe your situation on the reverse of this from or
on an additional page, if necessary.

4. Do you, your spouse, your minor children, or any blood relative
immediately	residing	in	your	household,	serve	as	an	officer,
director, committee member, or employee of any business entity
owning or operating any grain elevator or warehouse, or engage
in the merchandising, storage, commercial transportation, or
other commercial handling of grain?
5. Do you, your spouse, your minor children, or any blood relative
immediately residing in your household, have stock or other
financial	interest,	directly	or	indirectly,	in	any	grain	elevator	or
warehouse or any other business entity involved in the
merchandising, storage, commercial transportation, or other
commercial handling of grain?
6. Do you know of any other matters, family relationships or other
personal relationships, which might give rise to an apparent or
possible	conflict	of	interest	involving	your	present	employment
and any business entity described above?

7. Signature

YES

NO

YES

NO

YES

NO

8. Date

PRIVACY ACT STATEMENT

Mandatory	response	to	the	above	Conflict	of	Interest	Questionnaire	is	required	by	7	U.S.C.	87	Section	11.	Failure	to	
provide	information	may	result	in	the	Official	Agency	not	receiving	Federal	designation/delegation	as	an	Official	Agency.	
Information	will	be	used	to	evaluate/resolve	possible	conflicts	of	interest	an	also	may	be	referred	the	Department	of	Justice	
or	to	other	investigative	and	law	enforcement	agencies	for	investigation,	prosecution,	and/or	administrative	action	resulting	
from	violation	of	law,	rule,	regulation,	instruction,	or	order;	or	to	a	Congressional	office	in	response	to	a	constituents	
request	for	release	of	his/her	record.	18	U.S.C.	1001	provides	for	a	fine	of	not	more	than	$10,000	or	imprisonment	for	not	
more	than	5	years,	or	both,	for	false	or	fraudulent	statements	made	to	an	agency	of	the	United	States.

CLEAR FORM
Form FGIS-100 (01/24) Previous editions are obsolete. Expires 03-25

Instructions for Completing FGIS-100
Please type application or print carefully. Additional sheets may be used to describe your situation, if
necessary.
1. Provide the full legal name of non-licensed employee of an official agency.
This includes first, middle, last, and suffix (e.g., Sr., Jr., and III). If the
employee does not have a middle name or initial, please check the button
signifying so.	.
2. Provide	the	name	of	the	official	agency	that	employs	the	individual.
3. Provide	the	name	of	the	position	or	organizational	title	in	the	official	agency.
4. Check the block left of “YES” if true; check in the block left of “NO” if not true.
5. Check the block left of “YES” if true; check in the block left of “NO” if not true.
6. Check the block left of “YES” if true; check in the block left of “NO” if not true.
7. Sign	full	name.

Contact Information
8. Provide date signed.
Submit with an Application for Designation (Form FGIS - 942) or upon any change in non-licensed
personnel. Send using any of the following methods:
•

E-mail: Send via electronic mail to [email protected]

•

Hand Delivery, Courier, or Mail to:
Quality Assurance & Compliance Division, AMS, FGIS, USDA
1400 Independence Avenue, SW., Room 2409-S; STOP 3630
Washington, DC 20250

For further information contact:
Director
Quality Assurance & Compliance Division
1400 Independence Avenue, SW, Room 2409-S
Washington, DC 20250
Telephone: (202) 720-0228
Email: [email protected]
AMS website: http://www.ams.usda.gov


File Typeapplication/pdf
File TitleFGIS 100
File Modified2024-09-09
File Created2018-05-03

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