Va Form 0893 - Advance Review Of Offer To Donate Support For Official Travel Page 2

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TO YOUR KNOWLEDGE, ARE THERE ANY PENDING CONTRACTS, PROPOSALS, REQUESTS FOR PROPOSALS, AFFILIATION AGREEMENTS, OR OTHER

DECISIONS OR MATTERS INVOLVING VA AND DONOR?

YES (If "YES", describe the pending matter in the REMARKS section below.)

DOES VA EMPLOYEE HAVE A ROLE IN VA ACTION ON ANY OF THE PENDING MATTERS?

YES (If "YES," describe the VA Employee's role in the REMARKS section below.)

IF REIMBURSEMENT WILL BE BY CASH OR CHECK PAYABLE TO EMPLOYEE ANSWER THE FOLLOWING:

1. IS THE DONOR A TAX-EXEMPT 501(c)(3) CORPORATION?

YES

2. DID YOU RENDER SERVICE TO THE 501(c)(3) DONOR PRIOR TO THIS TRAVEL? (If yes, provide details in REMARKS sections below.)

YES

REMARKS

SIGNATURE OF EMPLOYEE (Traveler)

DATE SIGNED

CERTIFICATION: I certify that the answers above are

truthful and correct. I further certify that if I directly

receive a cash or check payment from the donor, I will use

these funds only for the listed travel expenses and I will

refund any unused portion of these funds to the donor.

CERTIFICATION OF HEAD OF EMPLOYEE-TRAVELER'S OFFICE

SIGNATURE OF REQUESTING OFFICE HEAD OR NEXT HIGHER

DATE SIGNED

CERTIFICATION: I certify that the travel relates to the

OFFICIAL IF REQUESTING HEAD IS TRAVELER (Print name and title)

employee's official duties and believe that the travel is in

the interest of the Government. To the best of my

knowledge, I believe that the answers above are truthful

and correct.

GENERAL COUNSEL REVIEW

DATE SIGNED

SIGNATURE OF ASSISTANT GENERAL COUNSEL (023) OR

REGIONAL COUNSEL OR OTHER DEPUTY ETHICS OFFICIAL

REVIEW FINDINGS: Based upon facts above, VA could

lawfully determine that accepting the offered travel support

would be proper.

ACCEPTANCE OF GIFT BY AUTHORIZED OFFICIAL

I approve acceptance of the gift of travel support based on the facts provided above. I determine that the travel is in the interest of the Government

and relates to the traveling employee's official duties and that the gift is not a reward for services to the donor prior to the event. I further determine

that acceptance of the offered travel support would not cause a reasonable person with knowledge of all the relevant facts to questions the integrity

of VA's programs, operations, or employee's. I have considered any impact the performance or nonperformance of the traveling employee's official

duties might have on the donor.

SIGNATURE OF APPROVING OFFICIAL (Print name and title)

LIST OF OFFICIALS AUTHORIZED TO MAKE DETERMINATION

DATE SIGNED

Secretary; Deputy Secretary, VA COS, VA Deputy COS,

Under Secretary, Deputy Under Secretary, Assistant

Deputy Under Secretary, Executive Assistant to the Under

Secretary, Assistant Secretary, Deputy Assistant

Secretary, Key Central Office Official and Deputy; VISN

Director and Deputy Director, VBA Area Director and