NIST NEPA financial disclosure statement - 1-9 V2

OMB Control Number: 0693-XXXX
Expiration Date: XX/XX/XXXX

National Institute of Standards and Technology
NEPA Disclosure Statement
FOR PREPARATION OF THE PROJECT
[ENVIRONMENTAL ASSESSMENT/ENVIRONMENTAL IMPACT STATEMENT]
The Council on Environmental Quality (CEQ) National Environmental Policy Act (NEPA)
implementing regulations require applicants or contractors that will prepare an environmental
assessment or environmental impact statement under the supervision of the lead agency to execute a
disclosure specifying any financial or other interest in the outcome of the project. 40 C.F.R. §
1506.5(b)(4).
In accordance with these requirements,
shall complete this document.
, on behalf of itself, its subsidiaries, and its employees, hereby certifies
as follows, to the best of its knowledge as of the date set forth below:
(a)
(b)

outcome of the project; OR

has no financial or other interest in the

has no financial or other interest in the
outcome of the project other than those specified in Exhibit A hereto.

Certified by:
Name
Company
Date

Title

Exhibit A to
National Institute of Standards and Technology
NEPA Disclosure Statement
FOR PREPARATION OF THE PROJECT
[ENVIRONMENTAL ASSESSMENT/ENVIRONMENTAL IMPACT STATEMENT]
Description of financial or other interests in project:1

Such disclosure is not required to include privileged or confidential trade secrets or other confidential business
information (40 C.F.R. § 1506.5(b)(4)).
1

Burden Statement
A Federal agency may not conduct or sponsor, and a person is not required to
respond to, nor shall a person be subject to a penalty for failure to comply with an
information collection subject to the requirements of the Paperwork Reduction Act
of 1995 unless the information collection has a currently valid OMB Control
Number. The approved OMB Control Number for this information collection is
0693-XXXX. Without this approval, we could not conduct this information
collection. Public reporting for this information collection is estimated to be
approximately 15 minutes per response, including the time for reviewing
instructions, searching existing data sources, gathering, and maintaining the data
needed, and completing and reviewing the information collection. All responses to
this information collection are mandatory to obtain benefits. Send comments
regarding this burden estimate or any other aspect of this information collection,
including suggestions for reducing this burden to the National Institute of
Standards and Technology at: Attn: Cierra Bean, Business Operations Analyst,
CHIPS Program Office and askchips@chips.gov.