FGIS 100 Conflict-on-Interest Questionnaire (Non Licensed Officia

FORM APPROVED OMB NO. 0580-0013
UNITED STATES DEPARTMENT OF AGRICULTURE
GRAIN INSPECTION, PACKERS AND STOCKYARDS ADMINISTRATION
FEDERAL GRAIN INSPECTION SERVICE
COMPLIANCE DIVISION

According to the Paperwork Reduction Act of 1995, an agency
may not conduct or sponsor, and a person is not required to
respond to a collection of information unless it displays a valid
OMB control number. The valid OMB control number for this
information collection package is 0580-0013. The time required
to complete this information collection is estimated to average
5 minutes per response, including the time for reviewing
instructions, searching existing data sources, gathering and
maintaining the data needed, and completing and reviewing
the collection of information.

CONFLICT OF INTEREST QUESTIONNAIRE
( NON-LICENSED OFFICIAL AGENCY PERSONNEL)

1. Name (Print) (Last, First, Middle Initial)
2. Official Agency

3. Position or Relationship to Official Agency

Please indicate your answer to each of the following questions by entering an “X” in the appropriate space. If your
answer to any questions is “YES”, or if you desire to elaborate on any of your answers, please describe your situation
on the reverse of this from or on an additional page, if necessary.

4. Do you, your spouse, your minor children, or any blood relative
immediately residing in your household, serve as an officer,
director, committee member, or employee of any business entity
owning or operating any grain elevator or warehouse, or engage
in the merchandising, storage, commercial transportation, or
other commercial handling of grain?

5. Do you, your spouse, your minor children, or any blood relative
immediately residing in your household, have stock or other
financial interest, directly or indirectly, in any grain elevator or
warehouse or any other business entity involved in the
merchandising, storage, commercial transportation, or other
commercial handling of grain?
6. Do you know of any other matters, family relationships or other
personal relationships, which might give rise to an apparent or
possible conflict of interest involving your present employment
and any business entity described above?

7. Signature

YES

NO

YES

NO

YES

NO

8. Date

PRIVACY ACT STATEMENT
Mandatory response to the above Conflict of Interest Questionnaire is required by 7 U.S.C. 87 Section 11. Failure to provide
information may result in the Official Agency not receiving Federal designation/delegation as an Official Agency. Information will be
used to evaluate/resolve possible conflicts of interest an also may be referred the Department of Justice or to other investigative
and law enforcement agencies for investigation, prosecution, and/or administrative action resulting from violation of law, rule,
regulation, instruction, or order; or to a Congressional office in response to a constituents request for release of his/her record. 18
U.S.C. 1001 provides for a fine of not more than $10,000 or imprisonment for not more than 5 years, or both, for false or fraudulent
statements made to an agency of the United States.

Form FGIS -100 (07-04) Previous editions are obsolete. Expires xx/xx/20xx
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INSTRUCTIONS FOR COMPLETING FORM FGIS-100 –CONFLICT OF INTEREST QUESTIONNAIRE
Please type application or print carefully. Additional sheets may be used to describe your
situation, if necessary.
(1) Provide the name of the individual non-licensed employee of an official agency.
(2) Provide the name of the official agency that employs the individual.
(3) Provide the name of the position or organizational title in the official agency.
(4) Check the block left of “YES” if true; check in the block left of “NO” if not true.
(5) Check the block left of “YES” if true; check in the block left of “NO” if not true.
(6) Check the block left of “YES” if true; check in the block left of “NO” if not true.
(7) Sign full name.
(8) Provide date signed.
CONTACT INFORMATION:
Submit with an Application for Designation (Form FGIS - 942) or upon any change in nonlicensed personnel. Send using any of the following methods:
•

Hand Delivery or Courier: Deliver to Chief, Review Branch, Compliance Division, GIPSA,
USDA, Room 1647-S, 1400 Independence Avenue, SW., Washington, DC 20250

•

Fax: Send by facsimile transmission to (202) 720-7786, attention: Review Branch

•

E-mail: Send via electronic mail to Samantha.J.Simon@usda.gov

•

Mail: Send to Director, Quality Assurance & Compliance Division, GIPSA, USDA, STOP 3604,
1400 Independence Avenue, SW., Washington, DC 20250-3604.
For further information contact:
Director
Quality Assurance & Compliance Division
1400 Independence Avenue, SW, Room 1647-S
Washington, DC 20250
Telephone: (202) 690-3206
Fax: (202) 720-7786
Email: Samantha.J.Simon@usda.gov
GIPSA website:

http://www.gipsa.usda.gov