ACUS Form 1 Substitute Non-government Member Confidential Employment

OMB Control No. 3002 - 0003
Expiration Date:_____________
ACUS Form 1

Administrative Conference of the United States
Non-Government Member Confidential Employment
and Financial Disclosure Report

Public members of the Administrative Conference of the United States (ACUS) are deemed to be
special government employees within the meaning of 18 U.S.C. § 202(a) and, therefore, are
subject to confidential financial disclosure requirements of the Ethics in Government Act, 5
U.S.C. App. § 107, and U.S. Office of Government Ethics (OGE) regulations. Under ACUS
Bylaws § 302.5, Avoidance of Conflicts of Interest, non-government senior fellows, special
counsels, and liaison representatives are subject to the same confidential financial disclosure
requirements as public members.
This form is a substitute for OGE Form 450, which ACUS public members otherwise would be
required to file. It was approved by the Director of the Office of Government Ethics following a
determination by the ACUS Chairman, pursuant to 5 C.F.R. § 2634.905(a), that greater
disclosure by public members is not required because the duties of a member make remote the
possibility that a real or apparent conflict of interest will occur.
As required by the Ethics in Government Act, 5 U.S.C. App. § 107(a); Executive Order 12674,
§ 201(d); and OGE regulations, 5 C.F.R. § 2634.901(d), this report will be held in strict
confidence.
PART I: GENERAL INFORMATION

Name: __________________________________________________________________
E-mail address: __________________________________________________________
Telephone number: _______________________________________________________
Employer: _______________________________________________________________
Occupation or position title: ________________________________________________
PART II: OUTSIDE POSITIONS

Report any outside positions, whether or not compensated, which you held outside the U.S.
Government in the last year but only if such positions involved responsibilities that relate in

some way to the subject matter of any item on the agenda of the upcoming ACUS plenary
session. You need not report any positions of your spouse or dependent children.
Note: Positions include but are not limited to those of an employee, officer, director, trustee,
general partner, proprietor, representative, or consultant of any corporation, firm, partnership, or
other business entity, or any non-profit or volunteer organization or educational institution.
Exclude positions with religious, social, fraternal, or political entities or those solely of an
honorary nature.
None______
1._____________________________________________________________________
2._____________________________________________________________________
3._____________________________________________________________________
PART III: AGREEMENTS AND ARRANGEMENTS

Report below any current agreements or arrangements for future employment, leaves of absence,
payment by a former employer (including severance payments), or continuing participation in an
employee benefit plan, but only if such agreements or arrangements relate in some way to the
subject matter of any item on the agenda of the upcoming ACUS plenary session. You need
not report any agreements or arrangements of your spouse or dependent children.
None______
1._____________________________________________________________________
2._____________________________________________________________________
3._____________________________________________________________________

PART IV: ASSETS, INCOME AND LIABILITIES

Identify for yourself, your spouse, and dependent children: (1) each asset held for investment or
the production of income that exceeds $1,000 in value (excluding accounts in banks, savings and
loans and similar depository institutions, and U.S. Government obligations, such as U.S. savings
bonds and government-issued securities); (2) each asset or source of income which generated
over $200 in income in the previous year; and (3) any liabilities over $10,000 (excluding a
residential mortgage, consumer loans, and liabilities owed to immediate family members), but
only if such assets, income, and liabilities relate in some way to the subject matter of any item

2

on the agenda of the upcoming ACUS plenary session. Report only the identity and nature of
income; do not include the amount or value of assets, income, or liabilities.
Note: This part is intended to require no greater disclosure than is required by OGE Form 450,
which would require disclosure of assets, income and liabilities regardless of their relevance to
ACUS matters. However, because OGE’s regulations on disclosure of assets, income, and
liabilities contain additional exclusions from reporting, members are advised to consult with the
ACUS General Counsel/Designated Agency Ethics Official if they have questions about the
reporting of assets, income, and liabilities described above.
None_____
1._____________________________________________________________________
2._____________________________________________________________________
3._____________________________________________________________________

I certify that the statements I have made on this form are true, complete, and correct to the best
of my knowledge.
Signature______________________________________________________ _ Date_______

3

Privacy Act Statement
Title I of the Ethics in Government Act of 1978 (5 U.S.C. App.), Executive Order 12674, 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 report is for review by the
Administrative Conference, 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 agency becomes aware of a violation of
the 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 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 and inspections; (5) to the Office of Management and Budget during legislative
coordination on private relief legislation; and (6) in response to a request for discovery or for the
appearance of a witness in a judicial or administrative proceeding, if the information is relevant
to the subject matter. This confidential report will not be disclosed to any requesting person
unless authorized by law.
Falsification of information or failure to file or report information required to be reported may
subject you to disciplinary action by the appropriate authority. Knowing and willful falsification
of information required to be reported may also subject you to criminal prosecution.

Paperwork Reduction Act Statement
The average burden for each response to this information collection is estimated to be less than
15 minutes. Any comments concerning the accuracy of this burden estimate and any suggestions
for reducing this burden may be directed to the Office of the Chairman of the Administrative
Conference.
An agency may not conduct or sponsor and a person is not required to respond to a collection of
information unless it displays a current valid OMB control number.

4