Form OSM 23 OSM 23 State Employee Statement of Employment and Financial Int

UNITED STATES DEPARTMENT OF THE INTERIOR

FORM OSM 23 (8/89)

Approved by OMB

Office of Surface Mining Reclamation and Enforcement

CN 1029-0067

State Employee Statement of Employment and Financial Interest
1. Name (Last, First, Initial)

2. Title of Position

3. Date of Appointment (in present position)

4. Organizational Unit

5. Duty Station (Office location)

6. Telephone No.

Expires: 7/31/17

7. Calendar Year (previous)

General Instructions. Report all interests held during the previous calendar year (indicate which ones are no longer held), use attachments as necessary.
In the event that any of the required information is not known to you, but is known to another person (e.g., trustee, accountant, relative), request that
the other person submit the information on your behalf. Provide the name and address of the other person, and include the date you requested the
information to be supplied. Briefly explain the situation and the information requested. Codes: (E) for Employee, (J) for Joint ownership with
spouse, minor child or other relatives, (S) for Spouse, (C) for minor child or (R) for other Relatives who are full-time residents in your immediate
household.
Part I. Employment and Securities. List the names of business entities, non-profit organizations, educational and other institutions in which you,
your spouse, minor child or other relatives who are full-time residents of your immediate household have a financial interest, including but not limited
to: (1) an interest as an employee, officer, owner, director, trustee, partner or consultant; (2) a continuing financial interest through a pension or
retirement plan, individual retirement account, shared income, or other arrangement as a result of any current or prior employment; (3) any financial
interest through the ownership of stock, bonds, securities or other arrangement including trusts. You may exclude: (1) positions with charitable,
religious, fraternal, political organizations or any similar organization and those solely of an honorary nature; (2) holdings in widely held diversified
mutual funds, investment clubs or regulated investment companies not specializing in underground and surface coal mining operations; (3)
employment, pension or retirement plans with the U.S. or State Governments; and (4) retirement plans with a guaranteed income. A guaranteed income
is one which is unlikely to be changed as a result of actions taken by the State regulatory authority.
NONE
Code J, S,
C or R

Name and Address of Organization

Description of Interest
(e.g., employment, stock)

Nature of Employment and Financial
Interest (e.g., salary, dividends)

Part II. REAL PROPERTY. List property in which you, your spouse, minor child or other relatives who are full-time residents of your
immediate household have an interest. Exclude your personal residence. Personal residence means any real property used exclusively as a private
dwelling.
NONE
Code J, S,
C or R

Nature of Interests (e.g., ownership,
lease, royalty, mineral rights)

Description of Interest
(e.g., employment, stock)

Location of Interest
(county and state)

Part III. CREDITORS. List debts owed to business entities and non-profit organizations to whom you, your spouse, minor child or other relatives
who are full-time residents of your immediate household are indebted. Exclude debts owed to financial institutions (e.g., banks, credit unions), credit
cards, and those for ordinary household and living expenses.
NONE
Code J, S,
C or R

Nature of Interests (e.g., ownership,
lease, royalty, mineral rights)

Description of Interest
(e.g., employment, stock)

Location of Interest
(county and state)

Part IV. EMPLOYEE CERTIFICATION. To the best of my knowledge, none of the employment and financial interests listed represents an interest
in an underground or surface coal mining operation except as follows:
NONE
Code J, S,
C or R

Nature of Interests (e.g., employment, mineral rights, stock, undeveloped land)

I certify that the statements I have made are true, correct, and complete to the best of my knowledge.
Signature of Employee

Date

Part V. REVIEWERS CERTIFICATION. Review completed and prohibited interests, if any, have been resolved. Reviewer’s comments, if any,
show the basis for the certification:

Signature of Reviewer

Date

PRIVACY AND PAPERWORK REDUCTION ACT NOTICES
Section 517(g) of Public Law 95-87, the Surface Mining Control and Reclamation Act, and 30 CFR 705, constitute the authority for collecting the
personal data on this statement of employment and financial interests. This data must be furnished. Knowing failure to file or report information
required may subject you to disciplinary action by your employing agency or other appropriate authority. Knowing failure to file or report information
required may also subject you to criminal prosecution leading to a fine of not more than $2,500 or imprisonment for not more than one year or both.
The information gathered from the statement will be used to determine whether there are any direct or indirect financial interests in violation of Section
517(g) of Public Law 95-87.
Maintenance of the statement by the State regulatory authority is subject to State law. Pursuant to 30 CFR 705 the statement may be inspected by or
provided to representatives of the U.S. Department of the Interior.
If the statement is provided to the U.S. Department of the Interior, the statement will be subject to the requirements of Federal law, including the Privacy
Act of 1974, 5 U.S.C. 552a. The U.S. Department of the Interior may make routine disclosures: (1) from the records of an individual in response to an
inquiry from a Congressional office made at the request of that individual; (2) to the U.S. Department of Justice when related to litigation or anticipated
litigation involving the records or the subject matter of the records; and (3) to appropriate State and Federal law enforcement agencies.
Public reporting burden for this form is estimated to average 5 minutes per response, including time for reviewing instructions, gathering and
maintaining data, and completing and reviewing the form. You are not required to respond to this collection of information unless it displays a currently
valid OMB control number. Direct comments regarding the burden estimate or any other aspect of this form to the Information Collection Clearance
Officer, Office of Surface Mining Reclamation and Enforcement, Room 203 SIB, 1951 Constitution Ave., NW, Washington, D.C., 20240.