Donor Certification Form SS-A-7-17-12

Supporting Statement A

Donor Certification Form

OMB Control Number 1090-0009

Terms of Clearance: None

General Instructions

A completed Supporting Statement A must accompany each request for approval of a collection of information. The Supporting Statement must be prepared in the format described below, and must contain the information specified below. If an item is not applicable, provide a brief explanation. When the question “Does this ICR contain surveys, censuses, or employ statistical methods?” is checked "Yes," then a Supporting Statement B must be completed. OMB reserves the right to require the submission of additional information with respect to any request for approval.

Specific Instructions

Justification

1. Explain the circumstances that make the collection of information necessary. Identify any legal or administrative requirements that necessitate the collection.

The Department and its individual bureaus all have gift acceptance authority. In support of the variety of donation authorities in the Department and increasing numbers of donations, it is the policy of the Department to ask those proposing to donate gifts valued at $25,000 or more to provide information regarding their relationship with the Department. The purpose of this policy is to ensure that the acceptance of a gift does not create legal or ethical issues for the Department, its bureaus, or potential donors.

Under the Departmental Manual, 374 DM 6, before any donation to the Department or its bureaus is accepted, the accepting employee must first determine that the circumstances of the donation maintain the integrity of the Department’s programs and operations, the impartiality and appearance of impartiality of the Department, and public confidence in the Department. However, not all gifts are large enough to request a written form with specified information to assist the Department in ensuring these factors. To determine an appropriate threshold above which such a form would be required, the Office of Acquisition and Management, the Office of the Solicitor, and involved bureaus jointly conducted a risk analysis. This risk analysis included examination of Inspector General Reports documenting examples in which proffers of gifts had been in some way potentially problematic. Based on this risk analysis, the parties concluded that $25,000 was the appropriate threshold above which there was a greater risk associated with possible legal or ethical questions for which the information in the form and certification thereto would be appropriate. In addition, the Departmental Manual Chapter on Donations, 374 DM 6, reflects the same $25,000 amount as the threshold at which this type of written documentation is requested for proffered donations.

The authorization under which the Department can collect this information is: 9 Stat. at L. 395, Ch. 108; 18 U.S.C. § 201, and 374 Departmental Manual (DM) 6. (Although 18 U.S.C. § 201 addresses topics related to the bribery of Government officials, by implication the fact that such acts are illegal logically empowers the Government to collect basic information about the circumstances surrounding proffers of significant donations, and imposes a duty to do so.)

The authorities under which the Department can accept donations include:

Outdoor Recreation Authority (16 U.S.C. § 460l): This law often is referred to as the Outdoor Recreation Act. The Act includes authorization for the Secretary to accept and use donations of money, property, personal services, or facilities to support outdoor recreation.

Stewardship of Federal, State and Local Lands (16 U.S.C. §§ 4601-4608 – “Take

Pride in America”): The Take Pride in America (TPIA) Program statute provides the

Department with very broad authority to establish and maintain a public awareness campaign in cooperation with public and private organizations and individuals, in order to instill in the public the importance of the appropriate use of, and appreciation for, Federal, State, and local lands, facilities, and natural and cultural resources; to promote an attitude of stewardship toward them; and to promote participation in caring for them. This statute also provides the Secretary the authority to solicit, accept, hold, and use donations of money and personal property.

BUREAU OF INDIAN AFFAIRS

25 U.S.C. § 451 allows the Secretary to accept donations of funds or other property for Indian advancement and use the donations in accordance with their terms.

25 U.S.C. § 500c allows the Secretary to receive gifts on behalf of Alaska natives to promote the reindeer industry.

25 U.S.C. § 458bbb et seq. require the Secretary to establish the American Indian Education Foundation, a non-profit, federally-chartered charitable corporation whose mission is to encourage, accept and administer private gifts of real and personal property in support of the BIA’s Office of Indian Education Programs. The Secretary may transfer to the Foundation funds held under 25 U.S.C. 451, if not prohibited by the terms of the donation.

25 U.S.C. § 2006(f) allows the Director of the Office of Indian Education to accept gifts and bequests for the benefit and use of certain Indian schools or BIA education programs.

Bureau of Land Management

Contributions 43 U.S.C. § 1737(c): Section 307(c) of FLPMA authorizes the Secretary to accept contributions or donations of money, services, and property for the management, protection, development, acquisition, and conveying of public lands.

Bureau of Reclamation

Acceptance of Non-Federal Funds (43 U.S.C. § 395): The Contributed Funds Act provides that “all funds paid by states, municipalities, districts, or private parties for investigations, surveys, construction work, or any other development work incident thereto involving operations similar to those provided for by the reclamation law, are covered into the reclamation fund and available for expenditure by Reclamation for the purposes for which contributed, without the need for further appropriation.”

Fish and Wildlife Service

Partnerships for Fish and Wildlife Purposes (16 U.S.C. § 661 et seq.): The Fish and Wildlife Coordination Act provides authority for the Secretary to enter into agreements with Federal and State agencies, as well as public and private organizations, to assist in the protection of fish and wildlife and their habitats. This broad authority includes provisions for the Secretary to receive donations of lands and funds, as well as to enter into grants and cooperative agreements for the benefit of fish and wildlife species and their habitat.

Partnerships for Wildlife Program (16 U.S.C. § 3741): The Partnerships for Wildlife Act establishes the Wildlife Conservation and Appreciation Fund, to receive appropriated funds and donations from the National Fish and Wildlife Foundation and other private sources to assist the State fish and game agencies in carrying out their responsibilities for the conservation of non-game species. Funds are provided to designated State agencies on a matching basis to assist in carrying out wildlife conservation and appreciation projects that are eligible under the statute.

Cooperation with the National Fish and Wildlife Foundation (16 U.S.C. § 3701 et seq.): The National Fish and Wildlife Foundation Establishment Act established the National Fish and Wildlife Foundation as a federally chartered charitable, non-profit corporation to administer donations of real or personal property, or interests therein, in connection with FWS programs and conservation activities on the United States. The Secretary appoints the members of the Foundation’s board, and the Director of the FWS serves as an ex-officio, non-voting member of the board.

Donations of Lands and Funds to Benefit Fish and Wildlife Species and Their

Habitats (16 U.S.C. § 661 et seq.): The authorities conveyed under the Fish and Wildlife

Coordination Act include specific authority for the Secretary to receive donations of lands and funds for the benefit of fish and wildlife species and their habitats.

Appropriated Funds and Donations for the Wildlife Program (16 U.S.C. § 3741): The Partnerships for Wildlife Act authorizes the Secretary to receive appropriated funds and donations from the National Fish and Wildlife Foundation and other private sources to assist the State fish and game agencies in carrying out their responsibilities for the conservation of non-game species. The donations are placed into the Wildlife Conservation and Appreciation Fund, for provision to designated State agencies.

Geological Survey

Gift and General Cooperation Authority (43 U.S.C. §§ 36a, 36b, and 36c): The

Department of the Interior Appropriation Act for FY 1987 created authority for USGS regarding the acceptance of contributions from public and private sources, and cooperation with other agencies in prosecution of projects. Section 36c provides “In fiscal year 1987 and thereafter the United States Geological Survey is authorized to accept lands, buildings, equipment, and other contributions from public and private sources and to prosecute projects in cooperation with other agencies, Federal State, or private.” Gift authority is also provided for scientific or technical books, manuscripts, maps and related materials for inclusion in the USGS library (§36a), and for lands and interests in lands for stream gaging stations and observation well sites (§36b).

BUREAU OF OCEAN ENERGY MANAGEMENT

Gift Authority (43 U.S.C. § 1473, Pub. L. 99-591): This law provides authority for the BOEM to accept “land, buildings, equipment and other contributions, from public and private sources, which shall be available for purposes provided for in this account.”

National Park Service

General Authority for NPS to Accept Donations (16 U.S.C. § 6): The Secretary is authorized to accept patented lands, rights-of-way over patented lands or others lands, buildings, or other property within the various national parks and national monuments, and moneys which may be donated for the purposes of the national park and monument system.

Donations for Museum Purposes (16 U.S.C. § 18f(a)): The Secretary is authorized to accept donations of money or other personal property and to hold, use, expend and administer them for museum purposes.

Donations to the National Park Foundation for the Benefit of NPS (16 U.S.C. § 19e-o):

Congress established the National Park Foundation in order to encourage private gifts of real and personal property or any income therefrom or other interest therein for the benefit of, or in connection with, the National Park Service, its activities, or its services, and to further the conservation of natural, scenic, historic, scientific, educational, inspirational or recreational resources for future generations. The Foundation may accept, receive, solicit, hold, administer and use any gifts, devises or bequests or any income therefrom or other interest therein for the benefit of the National Park Service, its activities or its services. Congress required the Foundation to design and implement a comprehensive program to assist and promote philanthropic programs of support at the individual national park unit level.

Donations and Bequests of Money, Personal Property and Less than Fee Interests in Historic Property (16 U.S.C. § 470w-2): The Secretary is authorized to accept donations and bequests of money and personal property for the purposes of historic preservation and to accepts gifts or donations of less than fee interests in any historic property where the acceptance of such interests will facilitate the conservation or preservation of such properties.

In addition NPS has a number of regional and site-specific authorities.

Office of Surface MinING

Gift Authority (30 U.S.C. § 1231(b)(3)): SMCRA authorizes OSM to accept donations for carrying out the purposes of the Abandoned Mine Reclamation Fund.

ALASKA AUTHORITIES

ANILCA § 1302 (16 U.S.C. § 3192): This section authorizes the Secretary to acquire by donation, exchange, purchase or otherwise lands within the boundaries of a conservation system unit other than National Forest Wilderness; and to acquire by donation or exchange lands which are contiguous to any conservation system unit established or expanded by ANILCA that are owned or validly selected by the State.

ANILCA § 1306(b) (16 U.S.C. § 3196(b)): This section authorizes the Secretary to lease or acquire by donation, exchange, purchase, or any other method (except condemnation) real property, office space, housing, and other necessary facilities for administrative sites and visitor facilities in Alaska.

2. Indicate how, by whom, and for what purpose the information is to be used. Except for a new collection, indicate the actual use the agency has made of the information received from the current collection. Be specific. If this collection is a form or a questionnaire, every question needs to be justified.

This information provides Department staff with the basis for beginning the evaluation as to whether the Department will accept the donation. The authorizing employee receives the donor certification form with the proposed donation. The employee then reviews the totality of circumstances surrounding the proposed donation to determine whether the Department can accept the donation and maintain its integrity, impartiality, and public confidence, as required by the Departmental Manual, Part 374, Chapter 6.

The items on the form mirror the considerations specified in 374 DM 6.10C. that authorizing employees must bring to bear as they determine whether to accept a proposed donation.

Question 1: I am / am not involved in litigation or other controversy with the Department or its bureaus.

This information is specified in 374 DM 6.10C(1). Whether the donor is involved in litigation or other disputes with the Department.

Question 2: I am / am not seeking or otherwise engaged in any type of financial or business relationship with the Department, for example, a contract, permit, lease, grant, or cooperative agreement.

This information is specified in 374 DM 6.10C(2). Whether the donor is seeking or is otherwise engaged in any type of financial or business relationship with the Department, for example, a contract, permit, lease, grant, or cooperative agreement.

Question 3: I have / have not been debarred, suspended, proposed for debarment, excluded or disqualified under the nonprocurement common rule, or otherwise declared ineligible from doing business with any Federal government agency.

This information is specified in 374 DM 6.10C(3). Whether the donor has been debarred, suspended, proposed for debarment, excluded or disqualified under the non-procurement common rule, or otherwise declared ineligible from doing business with any Federal government agency as specified in the CFR.

Question 4: This donation is / is not expected to be involved with marketing or advertising.

This information is specified in 374 DM 6.10C(4). Whether the donation is expected to be involved with marketing or advertising.

Question 5: I am / am not seeking to attach condition(s) to this donation.

This information is specified in 374DM 6.10C(5). The value and any applicable conditions of the donation. Also, this provides an opportunity for the donor to make a clear statement of any intended conditions.

Question 6: This donation is / is not part of a series of donations to the Department or its bureaus.

This information is specified in 374 DM 6.10C(6). Whether the donation is a singular event or part of a series of donations.

3. Describe whether, and to what extent, the collection of information involves the use of automated, electronic, mechanical, or other technological collection techniques or other forms of information technology, e.g., permitting electronic submission of responses, and the basis for the decision for adopting this means of collection. Also describe any consideration of using information technology to reduce burden and specifically how this collection meets GPEA requirements.

Prospective donors can obtain the form from Departmental and bureau offices or on-line at:

http://www.doi.gov/archive/nbc/formsmgt/forms/di3680.pdf

The completed form may be submitted by postal mail, facsimile, or email, depending on the preference of the prospective donor.

4. Describe efforts to identify duplication. Show specifically why any similar information already available cannot be used or modified for use for the purposes described in Item 2 above.

The information requested is specific to the prospective donor. If the donor has interactions with the Department, information regarding such interactions will be scattered throughout the Department. With eight major bureaus, 2500 locations and 70,000 employees, it is not possible to collect the information about a particular donor in a timely manner to respond to a proposed donation by a process of examining all of the potentially involved offices with whom a prospective donor may have interactions. Having the donor certify his interactions with the Department gives the authorized employee reviewing the proposed donation a basis from which to begin checking.

Also, having the donor provide the information on the form enables the authorizing employee to evaluate which information needs to be verified, and which can be accepted.

Finally, there is no other place where this information is readily available, as it pertains to proposed acts of donation contemplated by others.

5. If the collection of information impacts small businesses or other small entities, describe any methods used to minimize burden.

This very simple form does not have a significant impact or burden on small businesses. The form is only used in the event of a prospective donation of $25,000 or more. If such a proposed gift is contemplated by a small business, that organization will have the several requested items of information readily available for completion of the form.

6. Describe the consequence to Federal program or policy activities if the collection is not conducted or is conducted less frequently, as well as any technical or legal obstacles to reducing burden.

If the donor certification form is not used, the reviewing office will have greater difficulty complying with the Departmental Manual, at 374 DM 6, which asks the office to request in writing certain information from prospective donors for purposes of evaluating a proposed gift over $25,000. In addition, after the risk analysis described in the answer to Question 1 was concluded, it was decided that $25,000 was the appropriate threshold at which there was sufficient risk to the Department that it was deemed necessary to ask prospective donors to certify in writing the specific information described in the Departmental Manual chapter, which is also now captured in the collection instrument. Further, because of the need to more formally examine a gift at this level, and the specific types of required information to be sought, the absence of the form with its information would require the Department to locate information throughout the Department regarding relationships between the donor and the Department. Since there are nine major bureaus, 2500 locations and 70,000 employees, it is not possible to collect the information about a particular donor in a timely manner to respond to a proposed donation by a process of examining all of the potentially involved offices with whom a prospective donor may have interactions. Having the donor certify his interactions with the Department, in those cases where the risk has been deemed large enough to warrant this additional step, gives the authorized employee reviewing the proposed donation a basis from which to begin checking.

7. Explain any special circumstances that would cause an information collection to be conducted in a manner:

* requiring respondents to report information to the agency more often than quarterly;

* requiring respondents to prepare a written response to a collection of information in fewer than 30 days after receipt of it;

* requiring respondents to submit more than an original and two copies of any document;

* requiring respondents to retain records, other than health, medical, government contract, grant-in-aid, or tax records, for more than three years;

* in connection with a statistical survey that is not designed to produce valid and reliable results that can be generalized to the universe of study;

* requiring the use of a statistical data classification that has not been reviewed and approved by OMB;

* that includes a pledge of confidentiality that is not supported by authority established in statute or regulation, that is not supported by disclosure and data security policies that are consistent with the pledge, or which unnecessarily impedes sharing of data with other agencies for compatible confidential use; or

* requiring respondents to submit proprietary trade secrets, or other confidential information, unless the agency can demonstrate that it has instituted procedures to protect the information's confidentiality to the extent permitted by law.

None of the above special circumstances applies.

8. If applicable, provide a copy and identify the date and page number of publication in the Federal Register of the agency's notice, required by 5 CFR 1320.8(d), soliciting comments on the information collection prior to submission to OMB. Summarize public comments received in response to that notice and in response to the PRA statement associated with the collection over the past three years, and describe actions taken by the agency in response to these comments. Specifically address comments received on cost and hour burden.

The 60-day notice seeking public comments was published March 28, 2012 (77 FR 18850). No public comments were received in response to that notice.

Describe efforts to consult with persons outside the agency to obtain their views on the availability of data, frequency of collection, the clarity of instructions and recordkeeping, disclosure, or reporting format (if any), and on the data elements to be recorded, disclosed, or reported.

Consultation with representatives of those from whom information is to be obtained or those who must compile records should occur at least once every three years — even if the collection of information activity is the same as in prior periods. There may be circumstances that may preclude consultation in a specific situation. These circumstances should be explained.

We consulted with several prospective or past donors to obtain their views. Each individual consulted reported that the filling out of this form should take no longer than 15 to less than 30 minutes, hence we determined an estimated 20 minutes per form.

• Tom Cassidy, Director of Federal Programs, The Nature Conservancy, 4245 N. Fairfax Drive, Suite 100, Arlington, VA 22203-1637 703-841-4527

• Curt Buchholtz, Executive Director, Rocky Mountain Nature Association, Box 3100, Estes Park, CO 80517 970-586-0108

• Nina Chamber, Director of Programs, Sonoran Institute, 7650 E. Broadway, Suite 203, Tucson, Arizona 85710 406-587-7331

• Seth Levy, Public Lands Fellow, American Hiking Society 1422 Fenwick Lane, Silver Spring, MD 20910 301-565-6704 x 302

Our experience with the program over the past three years has confirmed the 20-minute estimate as accurate.

9. Explain any decision to provide any payment or gift to respondents, other than remuneration of contractors or grantees.

No payments or gifts will be provided to respondents.

10. Describe any assurance of confidentiality provided to respondents and the basis for the assurance in statute, regulation, or agency policy.

There is no assurance of confidentiality made to respondents.

11. Provide additional justification for any questions of a sensitive nature, such as sexual behavior and attitudes, religious beliefs, and other matters that are commonly considered private. This justification should include the reasons why the agency considers the questions necessary, the specific uses to be made of the information, the explanation to be given to persons from whom the information is requested, and any steps to be taken to obtain their consent.

No sensitive or private information is requested.

12. Provide estimates of the hour burden of the collection of information. The statement should:

* Indicate the number of respondents, frequency of response, annual hour burden, and an explanation of how the burden was estimated. Unless directed to do so, agencies should not conduct special surveys to obtain information on which to base hour burden estimates. Consultation with a sample (fewer than 10) of potential respondents is desirable. If the hour burden on respondents is expected to vary widely because of differences in activity, size, or complexity, show the range of estimated hour burden, and explain the reasons for the variance. Generally, estimates should not include burden hours for customary and usual business practices.

* If this request for approval covers more than one form, provide separate hour burden estimates for each form and aggregate the hour burdens.

Broken down by category, the projected number of annual respondents are:

Individuals or households 150

Businesses and organizations 386

State, Local or Tribal Government 16

TOTAL 552

At 20 minutes per response, the total annual burden is 184 hours.

* Provide estimates of annualized cost to respondents for the hour burdens for collections of information, identifying and using appropriate wage rate categories. The cost of contracting out or paying outside parties for information collection activities should not be included here.

Managerial rates for the categories of those making donations were used, because it is deemed likely that whether one is an individual, a household, a business, a unit of government or a Tribe making a gift to the Department of at least $25,000, the individuals administering such a gift are likely to be at a managerial level in terms of the value of their time. Therefore, the Managerial rates for wages were used. The figure for government (non-Federal) workers was $37.32 per hour; the figure for all others, or non-government, was $51.64 per hour. Both wage levels were determined from the appropriate BLS charts at http://www.bls.gov/oes/current/oes110000.htm.

Since the estimated time to complete the form is 20 minutes, each hourly wage was multiplied by .33. That sum was then multiplied by the appropriate level of benefits, namely 1.4 for non-government, and 1.5 for the government workers. (The benefits multiplier is derived from BLS news release USDL: 12-1124, June 7, 2012, at http://www.bls.gov/news.release/pdf/ecec.pdf.)

Thus, for the non-government donors we get: $51.64 per hour X 0.33 hours X 1.4 for benefits = $24.10 estimated annualized respondent cost. For the government donors we get: $37.32 per hour X 0.33 hours X 1.5 for benefits = $18.66 estimated annualized respondent cost.

This translates into the following:

Individuals or households (150 forms) $3,615

Businesses and organizations (386 forms) $9,301

State, Local, or Tribal Government (16 forms) $299

TOTAL $13,215

13. Provide an estimate of the total annual non-hour cost burden to respondents or recordkeepers resulting from the collection of information. (Do not include the cost of any hour burden already reflected in item 12.)

* The cost estimate should be split into two components: (a) a total capital and start-up cost component (annualized over its expected useful life) and (b) a total operation and maintenance and purchase of services component. The estimates should take into account costs associated with generating, maintaining, and disclosing or providing the information (including filing fees paid for form processing). Include descriptions of methods used to estimate major cost factors including system and technology acquisition, expected useful life of capital equipment, the discount rate(s), and the time period over which costs will be incurred. Capital and start-up costs include, among other items, preparations for collecting information such as purchasing computers and software; monitoring, sampling, drilling and testing equipment; and record storage facilities.

* If cost estimates are expected to vary widely, agencies should present ranges of cost burdens and explain the reasons for the variance. The cost of purchasing or contracting out information collection services should be a part of this cost burden estimate. In developing cost burden estimates, agencies may consult with a sample of respondents (fewer than 10), utilize the 60-day pre-OMB submission public comment process and use existing economic or regulatory impact analysis associated with the rulemaking containing the information collection, as appropriate.

* Generally, estimates should not include purchases of equipment or services, or portions thereof, made: (1) prior to October 1, 1995, (2) to achieve regulatory compliance with requirements not associated with the information collection, (3) for reasons other than to provide information or keep records for the government, or (4) as part of customary and usual business or private practices.

There are no significant expected non-hour costs to respondents. The total annual cost burden of this data collection requires no capital, start-up or O&M costs to respondents. The data are already known and documented by respondents – either records kept by management officials in their normal course of business or the personal knowledge of individuals. These data are collected on a voluntary basis to expedite processing of proposed donations and require no one to keep records that are not already kept as part of their normal business practices.

14. Provide estimates of annualized cost to the Federal government. Also, provide a description of the method used to estimate cost, which should include quantification of hours, operational expenses (such as equipment, overhead, printing, and support staff), and any other expense that would not have been incurred without this collection of information.

The average civil service grade level of processors is estimated to be GS-12, Step 5. These activities will occur nationwide. Using the 2012 OPM pay rates, base plus locality pay for the rest of the United States, and multiplying by a factor of 1.5 to include benefits, the salary figure for services associated with this form is estimated at $56.06 per hour ($37.37 X 1.5). (The salary level is based on the OPM site: http://www.opm.gov/oca/12tables/html/RUS_h.asp. The benefits multiplier is derived from BLS news release USDL: 12-1124, June 7, 2012, at http://www.bls.gov/news.release/pdf/ecec.pdf.)

It is estimated that it will take an average of 45 minutes to review and verify the form’s contents per donation. Three-fourths of the above hour rate yields a $42.05 salary cost per processed form, or $23,212 for all 552 forms.

15. Explain the reasons for any program changes or adjustments in hour or cost burden.

There is no change in the estimated burden.

16. For collections of information whose results will be published, outline plans for tabulation and publication. Address any complex analytical techniques that will be used. Provide the time schedule for the entire project, including beginning and ending dates of the collection of information, completion of report, publication dates, and other actions.

The results of this information collection will not be published.

17. If seeking approval to not display the expiration date for OMB approval of the information collection, explain the reasons that display would be inappropriate.

The donor certification forms will display the expiration date for OMB approval of the information collection.

18. Explain each exception to the topics of the certification statement identified in "Certification for Paperwork Reduction Act Submissions."

There are no exceptions to the certification statement.