Form 450 - Confidential Certificate Of No New Interests - U.s. Office Of Government Ethics
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2U.S. Office of Government Ethics
See Privacy Act and Penalties Statements
OGE Optional Form 450-A (08/2005)
on reverse side (or on following page)
Confidential Certificate of No New Interests
In Lieu of Annual OGE Form 450
This optional form is to be used only by current employees of the executive branch (other than special
Government employees), in accordance with 5 CFR 2634.905(d). If you have a previous OGE Form 450
on file with your agency and can certify to all of the following statements, your agency may permit you to
use this OGE Optional Form 450-A instead of filing an annual OGE Form 450. If you cannot certify to all of
the following statements or otherwise do not wish to use this OGE Optional Form 450-A, you must complete
a new OGE Form 450 as your annual report. Consult your agency ethics office for more information.
After examining a copy of my last confidential financial disclosure report (OGE Form 450), I certify to
the following:
A. No New Interests. Since filing my last OGE Form 450:
1. I have no new reportable assets or sources of income, for myself, my spouse, or my dependent children;
2. I have no new reportable liabilities (debts), for myself, my spouse, or my dependent children;
3. I have no new reportable outside positions for myself;
4. I have no new reportable agreements or arrangements concerning future, current, or past non-
Government employment for myself;
5. I have no new reportable gifts or travel reimbursements for myself, my spouse, or my dependent children.
(For a description of what interests are reportable, see OGE Form 450 and its accompanying
instructions, and/or other agency guidance.)
B. No Change in Position/Duties. Since filing my last OGE Form 450, I have not changed jobs at my
agency. (The term Achanged jobs@ includes a new position description or other significant change in duties.)
I certify that the above statements are true, complete and correct, to the best of my knowledge.
Signature of Employee _________________________________________ Date _______________________________
Printed Name ________________________________________________ Work Phone ________________________
Position/Title ______________________________________________ E-mail Address __________________________
Agency/Unit and Address _____________________________________________________________________________
FILERS MUST ATTACH A COPY OF THEIR MOST CURRENT OGE FORM 450 WITH THIS FORM.
Supervisor’s Certification. I have reviewed the interests reported on this form in light of the duties required by the reporting
individual=s position. I am satisfied that there is no actual or potential conflict of interest. (If remedial action is required or additional
explanation is necessary, use reverse side.)
Supervisor’s signature: __________________________________
(Check box if comments are included on reverse side.)
Date Received at DOD Ethics Office: _______________________
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