Form OGE Form 201-A OGE Form 201-A Request to Inspect or Receive Electronic Copies of Execu

OGE Form 201-A
Form Approved OMB No. 3209-0002
(November 2012)

The OGE Form 201-A is used to request copies of public financial disclosure reports filed by federal executive
branch officers and employees pursuant to 5 U.S.C. app. 4 § 101. These records are available under the
Freedom of Information Act of 1967 (5 U.S.C. § 552) and the Ethics in Government Act of 1978 (5 U.S.C. app. 4
§ 402) and OGE’s regulations implementing these statutes.

Your Full Name:
(required)

Your City:
(required)

Your State:
(required)

Your Country:
(required)

WARNING: This request for access to a public financial disclosure report is an official government form (OGE Form
201-A). In completing this OGE Form 201-A, you are advised that any intentionally false or misleading statement,
certification, or response you provide in this form is a violation of law punishable by a fine or imprisonment, or both,
under 18 U.S.C. § 1001.

I am aware that pursuant to section 105(c) of the Ethics in Government Act of 1978, as amended, and 5 C.F.R.
§ 2634.603(f) of the implementing OGE regulations, it is unlawful for any person to obtain or use a report:
(1) for any unlawful purpose;
(2) for any commercial purpose, other than by news and communications media for dissemination to the general
public;
(3) for determining or establishing the credit rating of any individual; or
(4) for use, directly or indirectly, in the solicitation of money for any political, charitable, or other purpose.
The Attorney General may bring a civil action against any person who obtains or uses a report for any such prohibited
purpose as set forth above. The court may assess against such a person a penalty in any amount not to exceed
$11,000. Such remedy shall be in addition to any other remedy available under statutory or common law.

I am aware of the above prohibitions (required)

View Privacy Act Statement & Public Burden Information

Requests for Other Related Records

Form Approved OMB No. 3209-0002

U.S. Office of Government Ethics

Cancel

1201 New York Avenue, NW, Suite 500

Submit

Washington, DC 20005

Privacy Act Statement
Section 402 of the Ethics in Government Act of 1978, as amended (5 U.S.C. app. 4 § 402) authorizes the
solicitation of the information requested in this form. The primary use of the information on this form is to permit
officials of the recipient agency to consider and process your request for inspection or receipt of a copy, or
copies, of one or more OGE Form 278 Executive Branch Personnel Public Financial Disclosure Report filed on
or after January 1, 2012, or OGE Form 278-T Periodic Transaction Report to which you seek access. Failure to
furnish the information will result in this agency's inability to allow access to, or to provide a copy of, any
requested OGE Form 278 or OGE Form 278-T. Otherwise, furnishing the requested information is voluntary.
The information on this form itself may be publicly disclosed pursuant to the Privacy Act of 1974, the Freedom
of Information Act of 1967, or as otherwise authorized by law.
Additional disclosures of the information on this form may be made:
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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;
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;
to a source when necessary to obtain information relevant to a conflict of interest investigation or decision;
to the National Archives and Records Administration or the General Services Administration in records
management inspections;
to the Office of Management and Budget during legislative coordination on private relief legislation;
to the Department of Justice or in certain legal proceedings when the disclosing agency, an 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;
to reviewing officials in a new office, department or agency when an employee transfers from one covered
position to another;
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
to contractors and other non-Government employees working for the Federal Government to accomplish a
function related to an OGE Governmentwide system of records.

See also the OGE/GOVT-1 executive branchwide Privacy Act system of records.

Public Burden Information
Public burden reporting for this collection of information is estimated to take approximately five minutes per
OGE Form 201-A, including time for reviewing instructions, gathering and maintaining the data needed, and
completing and reviewing the collection of information. Send comments regarding the burden estimate or any
other aspect of this collection of information, including suggestions for reducing this burden to: the General
Counsel, U.S. Office of Government Ethics, 1201 New York Ave, Suite 500, Washington, DC 20005-3917.
Pursuant to the Paperwork Reduction Act, as amended, an agency may not conduct or sponsor, and no person
is required to respond to, collection of information unless it displays a currently valid OMB control number (that
number, 3209-0002, is displayed here and in the upper right-hand corner of the front page of this OGE Form
201-A).

Requests for Other Related Records
In addition to requests for access to public OGE Form 278 and OGE Form 278-T reports filed on or after
January 1, 2012, you may also request access to certain other agency records which are covered under the
access procedures of section 105 of the Ethics in Government Act and the implementing OGE regulations by
completing an OGE Form 201. Access requests for OGE Form 278 and SF 278 reports filed before January 1,
2012, are covered under section 105 of the Ethics in Government Act of 1978 and implementing OGE
regulations. Access requests for Other Covered Records related to OGE Form 278, SF 278, and OGE Form
278-T reports, whether filed on, before or after January 1, 2012, are covered under section 105 of the Ethics in
Government Act of 1978 and implementing OGE regulations. Please submit an OGE Form 201 Request to
Inspect or Receive Copies of OGE Form 278/SF 278 Executive Branch Personnel Public Financial Disclosure

Reports or Other Covered Records. Such Other Covered Records are: (1) Certificates of Divestiture; (2) Ethics
in Government Act qualified blind trust and qualified diversified trust instruments (other than those provisions
which relate to the testamentary disposition of the trust assets), the list of assets transferred to such trusts (and
of assets sold in the case of a qualified blind trust), as well as, in the case of trust dissolution, the report thereon
and the list of trust assets at that time, and the certificates of independence and compliance with respect to
qualified trusts; (3) 18 U.S.C. § 208(b)(1) and (b)(3) waivers granted by the recipient agency (after deletion of
any material withholdable pursuant to the Freedom of Information Act, 5 U.S.C. § 552 (see 18 U.S.C.
§ 208(d)(1)); (4) other OGE Form 201 filings; (5) cover letters for approved gifts reporting waiver requests; and
(6) cover letters for approved public reporting waiver requests for certain less than 130-day special Government
employees. If you wish to request an OGE Form 278 or OGE Form 278-T filed on or after January 1, 2012, you
may file an OGE Form 201 in lieu of an OGE Form 201-A, in order to facilitate a simultaneous request for OGE
Form 278/SF 278 filed before January 1, 2012, or any Other Covered Record. If you wish to request a copy of
an OGE Form 201-A, you may file a request under the Freedom of Information Act, 5 U.S.C. § 552.

Form Approved OMB No. 3209-0002

U.S. Office of Government Ethics

1201 New York Avenue, NW, Suite 500

Washington, DC 20005