Applicant Disclosure Form

OMB No. 3316-0060
Exp. Date 09/30/2013

Section 26a Permit and Land Use Application
Applicant Disclosure Form
By signing the Joint Application Form (Department of Army/TVA) or TVA’s Land Use Application and again below, you agree to disclose
any business, political, or financial interest that may present an actual or potential conflict of interest with TVA. If a new significant
business, political, or financial interest is obtained during the period of the time that the application is under review, you agree to file an
additional disclosure.
Disclose if any of the following apply to you (check all that apply

3

). I am:

An elected government official
A policy making level employee of an entity that regulates TVA or its activities
A management level employee of a power customer of TVA
A TVA Director
A TVA employee
An immediate family member of one of the above
A representative of a corporation or entity submitting an application and one of the above applies to me. Print entity or
corporation name, and identify which of the above applies to you.
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
A representative of a corporation or entity submitting an application and the corporation or entity has partners, investors, or senior
management that are one of the above. Print entity or corporation name, and identify the partner(s), investor(s), or senior
manager(s) and which of the above applies.
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
None of the above
Do you have any other business or personal relationships not covered in your answers above that could appear to be a conflict of
interest? (check one) Yes
No
If yes, provide more detail here.
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
By signing this form, you consent to this Applicant Disclosure Form being made available to the public in response to an appropriate
request, including, without limitation, a request made under the Freedom of Information Act.
Please sign and return this form with your application package. Your application cannot be processed without receipt of this
signed form.
Name of applicant (Printed) _____________________________________________________________________________________
Signature of Applicant ________________________________________________________ Date ____________________________
All applications and communications that occur as part of the application process may be made public to the extent permitted by
applicable law, including the Freedom of Information Act and the Privacy Act, and could be reviewed formally by the Office of Inspector
General (OIG). All written correspondence regarding your request may be forwarded to the TVA Chief Ethics and Compliance Officer
(CECO) and the OIG, and all oral communication between TVA and the applicant regarding this request may be documented and
maintained by TVA. Inquiries concerning your application from any person who falls into one of the categories described above will be
disclosed to the CECO and OIG.
Privacy Act Statement
This information is being requested in accordance with Sections 4(k), 15d, 26a, and/or 31 of the TVA Act; 40 U.S.C. § 1314; 30 U.S.C. § 185; 16 U.S.C. § 667b; and/or
40 U.S.C. § 483. Disclosure of the information requested is voluntary; however, failure to provide any required information or documents may result in a delay in
processing your application or in your application being denied. An application that is not complete will be returned for additional information. TVA uses this
information to assess the impact of the proposed project on TVA programs and the environment and to determine if the project can be approved. Information in the
application is made a matter of public record through issuance of a public notice if warranted. Routine uses of this information include providing to federal, state, or
local agencies, and to consultants, contractors, etc., for use in program evaluations, studies, or other matters involving support services to the program; to respond to a
congressional inquiry concerning the application or the applicable program; and for oversight or similar purposes, corrective action, litigation, or law enforcement.

TVA 17423A [09-23-2010]