Gift Disclosure Waiver Request - U.s. House Of Representatives

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This form should be used by any House Member, officer, or employee who is seeking a waiver
of the reporting requirements under the Ethics in Government Act (EIGA) for gifts the individual
received in connection with a wedding or engagement, the birth or adoption of a child, or a death
in the family (5 U.S.C. app. § 102(a)(2)(A)). You must have already sought and received from
the Committee a waiver of the House gift rule (House Rule 25, clause 5) for any such gifts. A
House Member, officer, or employee who wishes to request a financial disclosure waiver under
the EIGA for any other type of gift should contact the Ethics Committee at (202) 225-7103.
Submit this form to the Ethics Committee’s Office of Advice and Education in 1015
Longworth HOB. Once approved, this form will be returned to you, and a copy will be filed
with the Clerk of the House for public disclosure.
Name of Requester: _______________________________ Date: _______________________
Signature of Requester:
Employing Member/Committee: ___________________________________________________
Office Address: ________________________________________________________________
Telephone: ____________________________________________________________________
Date gift rule waiver granted: _____________________________________________________
Occasion for which a gift rule waiver is requested (check one):
___ Wedding/engagement
___ Birth/adoption of child
___ Death in family
Date (or anticipated date) of occasion: _________________________
Request Approved pursuant to 5 U.S.C. app. § 102(a)(2)(C):
Date: _______________________________
Susan W. Brooks, Chairwoman
Theodore E. Deutch, Ranking Member
Copy to: Legislative Resource Center, 135 CHOB
Last Updated 1/2017


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