3110-48 Confidential Financial Disclosure Form for Special Gover

OMB Control No. 2090-0029
Approval expires 05/31/2011

Confidential Financial Disclosure Form for Environmental Protection
Agency Special Government Employees (EPA Form 3110-48)
A. Why You Must File
Public service is a public trust. In order to uphold that trust, the Government must obtain certain confidential financial
information to ensure that there are no conflicts between your public service and your private interests.
B. Who Must File
This form is used by the Agency for Special Government Employees (SGEs) as defined under 18 U.S.C. 202 and candidates
to be SGEs.
C. Privacy Act Statement
Title I of the Ethics in Government Act of 1978 (5 U.S.C. App.), Executive Order 12674 (as modified by Executive Order
12731), and 5 CFR Part 2634, Subpart I, of the Office of Government Ethics regulations require the reporting of this information. 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 of the information on this report may be made: (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 court or party in a court or Federal administrative proceeding if the Government is a party or in order to comply
with a judge-issued subpoena; (3) to a source when necessary to obtain information relevant to a conflict of interest investigation or
decision; (4) to the National Archives and Records Administration or the General Services Administration in records management
inspections; (5) to the Office of Management and Budget during legislative coordination on private relief legislation; (6) to the
Department of Justice or in certain legal proceedings when the disclosing agency, and 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; (7) to reviewing officials in a new office, department or agency when an employee transfers from one covered position
to another, (8) 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, and (9) to contractors and other non-Government employees working for the Federal Government to accomplish
a function related to an OGE Government-wide system of records. This confidential report will not be disclosed to any requesting
person unless authorized by law.
D. Paperwork Burden Disclosure Notice
The public reporting and recordkeeping burden for this collection of information is estimated to average one hour per
response. Send comments on the Agency’s need for this information, the accuracy of the provided burden estimates, and any
suggested methods for minimizing respondent burden, including through the use of automated collection techniques to the Director,
Collection Strategies Division, U.S. Environmental Protection Agency (Mail Code 2822T), 1200 Pennsylvania Ave., NW,
Washington, D.C. 20460. Include the OMB control number in any correspondence. Do not send the completed form to that address;
instead, send your completed form as directed by the Agency official who sent it to you.
E. When to file
Candidates and newly-appointed special Government employees must fully complete this form before performing any work
for EPA. Subsequently, you must file a new form annually or as instructed by your agency ethics official. PLEASE NOTE: It is your
responsibility to notify the appropriate EPA ethics official of any changes to the information you provide in this form.
F. Where to file
Send your report to the address specified by the Agency or by the Agency ethics official. You may use additional blank
pages in any section if needed. Please note your name and supplemental page number on the continuation pages.

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.

EPA Form 3110-48 (7-08)

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OMB Control No. 2090-0029
Approval expires 05/31/2011

G. What is a Special Government Employee (SGE)?
The SGE category was created by Congress to employ individuals who provide important, but limited, service to the
Government. These employees are subject to a limited set of conflict of interest requirements. SGEs provide temporary service to the
Government (not to exceed 130 days during any period of 365 consecutive days with or without compensation). SGEs are often
recruited because they provide outside expertise or perspectives that might be unavailable among an agency's regular employees.
SGEs are generally used as advisory committee members, individual experts or consultants. However, some SGEs serve on Boards or
Commissions and are brought on pursuant to applicable statute. (See 18 U.S.C. §202(a) for more information.)
H. What is a conflict of interest?
18 U.S.C. §208 prohibits all employees (including SGEs) from participating in any particular Government matter that will
have a direct and predictable effect on their financial interests. It also prohibits employees from acting in Government matters that will
affect the financial interests of others with whom they have certain relationships. These relationships are:
• Spouse
• Minor child
• General partner
• Organization in which the individual serves as officer, director, trustee, general partner or employee
• Person or organization with which the employee is negotiating or has an arrangement concerning prospective employment.
I. What is a particular matter?
The term "particular matter" includes deliberations, decisions, or actions that are focused upon the interests of specific
persons or entities or an identifiable class of persons or entities. A particular matter does not extend to broad policy options or
considerations directed toward the interest of a large and diverse group of people. A particular matter may involve specific parties
(e.g., a contract, grant or case in litigation) or it may be a particular matter of general applicability that is focused on the interests of a
discrete and identifiable class of persons (such as an industry).
J. What is a direct and predictable effect?
A particular matter will have a direct effect on a financial interest if there is a close causal link between any decision or action
to be taken in the matter and any expected effect of the matter on the financial interest. However, a particular matter will not have a
direct effect on a financial interest if the link is attenuated, or is contingent upon the occurrence of events that are speculative, or that
are independent of, and unrelated to, the matter. Furthermore, a particular matter that has an effect on a financial interest only as a
consequence of its effects on the general economy is also not considered to have a direct effect on a financial interest. A particular
matter will have a "predictable" effect if there is a real (as opposed to speculative) possibility that the matter will affect a financial
interest. It is not necessary to know the magnitude of the loss/gain, and the dollar amount is immaterial.
K. What is an appearance of a loss of impartiality?
5 C.F.R. Part 2635, Subpart E contains provisions intended to ensure that an employee takes appropriate steps to avoid an
appearance of a loss of impartiality in the performance of his/her official duties. Where an employee knows that a particular matter
involving specific parties is likely to have a direct and predictable effect on the financial interest of a member of his/her household, or
knows that a person with whom he/she has a covered relationship is or represents a party to such a matter, and where the person
determines that the circumstances would cause a reasonable person with knowledge of the relevant facts to question his/her
impartiality in the matter, the employee should not participate in the matter unless he/she has informed the agency designee of the
appearance of a problem and received authorization from the agency designee.

EPA Form 3110-48 (7-08)

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OMB Control No. 2090-0029
Approval expires 05/31/2011

SECTION 1: Identifying Information and Record of Agency Review
Your Name:
Last Name:

First Name:

Middle Initial:

Your Certification:
I certify that information I have provided on this form and all attachments is true, complete and correct to the best of my knowledge.
Signature of Reporting Individual

Date:

Date Received by the Agency (for Agency use only):

Agency Review (for Agency use only):
Panel Name/Employing
Office
Intermediate Reviewer
Signature, Date
Final Reviewing Official
Signature, Date
Comments:

Panel Name/Employing
Office:
Intermediate Reviewer
Signature, Date
Final Reviewing Official
Signature, Date
Comments:

Panel Name/Employing
Office:
Intermediate Reviewer
Signature, Date
Final Reviewing Official
Signature, Date
Comments:

Panel Name/Employing
Office:
Intermediate Reviewer
Signature, Date
Final Reviewing Official
Signature, Date
Comments:

EPA Form 3110-48 (7-08)

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OMB Control No. 2090-0029
Approval expires 05/31/2011

SECTION 2: Your Employment/Consulting/Volunteer Work
Report any employment or consulting, whether or not for compensation, for you and/or your spouse for the last two years preceding
the date of filing. Do not include any compensated expert testimony as these are reported in another part of this form. Don’t forget
to include your current employer as well as your spouse’s employer. You may indicate (S) for employment of your spouse. You
should report any of the following positions that you hold, whether or not for compensation: employee, officer, director, trustee,
general partner, proprietor, representative/executor of any business, consulting firm, non-profit, labor organization, or educational
institution. Also include any organization or person with whom you are negotiating or have an arrangement concerning prospective
employment. You may exclude unpaid positions with any religious, social, fraternal or political entities, or those solely of an
honorary nature, but you have to include any positions held with professional societies. You may add additional pages as necessary.
If you have NO employment at all, enter NONE below.

Organization (Name,
City, State). If reporting
consulting, Name of
Project and Client.
Example: East-West
University, Anywhere,
KS

Name of position and description of work. If you are employed by a consulting firm, indicate the firm’s
major practice areas, categories of principal clients, and the clients you or your spouse have dealt with
directly or derived compensation from. If reporting independent consulting, provide a description and
date(s) of the project.
Example: Dean, School of Environmental Studies.

Example: ABC
Corporation, Smallville,
VA

Example: Consultant on toxicological effects of heavy metals in wastewater from company facilities.
July 2007-July 2011.

EPA Form 3110-48 (7-08)

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OMB Control No. 2090-0029
Approval expires 05/31/2011

Continuation of Section 2 (if needed). Otherwise, continue to Section 3

Organization (Name,
City, State). If reporting
consulting, Name of
Project and Client.

EPA Form 3110-48 (7-08)

Name of position and description of work. If you are employed by a consulting firm, indicate the firm’s
major practice areas, categories of principal clients, and the clients you or your spouse have dealt with
directly or derived compensation from. If reporting independent consulting, provide a description and
date(s) of the project.

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OMB Control No. 2090-0029
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SECTION 3: Compensated Expert Testimony
Report any expert testimony for you or your spouse for the last two years preceding the date of filing. You may indicate (S) for
spouse. If you have NO compensated expert testimony, enter “NONE” below.
Client Name, City, State

Description & Date of Testimony. Include citation if available.

Example: XYZ law firm,
Anytown, CA

Example: Provided expert testimony for ABC corporation (plaintiff) on effects of heavy metals
in wastewater from company facilities. ABC Corporation v. XYZ, Civil Action No. 07-1234,
Superior Court of Anywhere, July, 2007.

EPA Form 3110-48 (7-08)

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OMB Control No. 2090-0029
Approval expires 05/31/2011

SECTION 4: Research Support/Project Funding
Report any source of research or project funding (e.g., grants, contracts, or other mechanism) that you or your spouse have received in
the last two years preceding the date of filing from any source (including state, federal or local government, private sector companies,
or non-profit organizations). You may indicate (S) for research support or project funding received for your spouse. Add any
additional pages as necessary. If you have NO research support or project funding, enter “NONE” below.
Funding
Organization
(Name, City, State)
If EPA, include
Office

Exact Title of Project. Include start and completion dates. Please also indicate whether funded through
grant, cooperative agreement, or contract. If a grant, include whether awarded competitively or not. If an
EPA grant include Project Officer and grant number.

Example:
Foundation for a
Cleaner Tomorrow,
Washington, DC

Example: Competitive Grant: “Mitigation Technologies for Volatile Organic Compounds” July 2007-July
2011.

Example: EPA,
Office of Research
and Development,
Cincinnati, OH

Example: Competitive Grant: “Health Effects of Long-Term Exposure to Air Pollutants in Nonsmoking
Virginia Residents” Project Officer: Jane Doe. EPA Grant Number R123456. March 2000 – Feb. 2003

EPA Form 3110-48 (7-08)

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OMB Control No. 2090-0029
Approval expires 05/31/2011

SECTION 5: Assets
Report for yourself, spouse, and dependent children any assets currently held for investment that are valued at more than $1,000 or
that generate more than $200 per year in income. You may distinguish any entry for a family member by preceding it with (S) for
spouse, (DC) for dependent child, or (J) for jointly held. You may also add additional pages if needed. If you have NO reportable
assets, enter “NONE” below.
Types of assets to report include (but are not limited to):
• Stocks, bonds, annuities, trust holdings, partnership interests, life insurance, investment real estate or a privately-held trade or
business. For real estate or a privately held business, report the type and city/state of the entity.
• Sector mutual funds, which are funds invested in a particular industry, business, or location such as ABC Electronics Fund or
XYZ Canada Fund. Please report the full name of the fund, not just the general family fund name.
• Individual holdings of retirement plans like 401(k)s or IRAs. List each holding except diversified mutual funds (see below)
• Holdings of investment life insurance or variable annuities
• Defined benefit pension plans (include name of employer)
Do NOT report:
• Certificates of deposit, savings accounts or checking accounts or any deposit in a bank, credit union or similar financial
institution
• Term life insurance
• Money market mutual funds or money market accounts
• Your personal residence (unless you rent it out)
• Diversified mutual funds, such as ABC Equity Value Fund or XYZ Large Capital Fund
• U.S. Government securities (e.g., treasury bonds, treasury bills, treasury notes, U.S. savings bonds or any securities issued by
U.S. Government agencies or Government sponsored corporations such as the Tennessee Valley Authority)
• Money owed to you, your spouse, or dependent child by a spouse, parent, sibling, or child
• Social Security Benefits
• Federal Government salary or retirement benefits
• Veterans’ benefits
• Alimony
• Child Support
• Underlying holdings of a trust that was not created by you, your spouse or dependent children and for which you, your
spouse and dependent children have no past or present knowledge of the holdings or sources of income
Definitions:
Dependent Child: A son, daughter, stepson or stepdaughter who is either: (1) unmarried and under age 21 and living in the filer’s
house, or (2) considered dependent under the U.S. tax code.
Diversified Mutual Fund: A mutual fund that does not have a policy of concentrating its investments in an industry, business, single
country other than the United States or single state within the United States.
Full Name of Asset. Include stock ticker symbol or other identifying information as appropriate.
Example: DEF Corporation (DEFC)

Example: JKL Energy Fund (JKLE)

EPA Form 3110-48 (7-08)

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OMB Control No. 2090-0029
Approval expires 05/31/2011

Continuation of Section 5 (if needed). Otherwise, continue to Section 6.
Full Name of Asset. Include stock ticker symbol or other identifying information as appropriate.

EPA Form 3110-48 (7-08)

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OMB Control No. 2090-0029
Approval expires 05/31/2011

SECTION 6: Supplemental Ethics Questions for Special Government Employees Serving on Advisory
Panel/Committees/Subcommittees
If you are serving or are a candidate to serve on an advisory panel/committee/subcommittee, please answer the following questions:
Do you know of any reason that you might be unable to provide impartial advice on the matter to come before the
panel/committee/subcommittee or any reason that your impartiality in the matter might be questioned?

Have you had any previous involvement with the review document(s) under consideration including authorship, collaboration with the
authors, or previous peer review functions? If so, please identify and describe that involvement.

Have you served on previous advisory panels, committees or subcommittees that have addressed the topic under consideration? If so,
please identify those activities.

Have you made any public statements (written or oral) on the issue that would indicate to an observer that you have taken a position
on the issue under consideration? If so, please identify those statements.

You may attach extra sheets if needed.

EPA Form 3110-48 (7-08)

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