Form For Disclosing Gifts From Foreign Governments Or International Organizations - House Committee On Ethics Page 2

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c.
Travel or travel expenses of more than minimal value for which you were reimbursed
by the foreign government or international organization (including transportation, food,
lodging, and entertainment) (describe):
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
7. CIRCUMSTANCES UNDER WHICH GIFTS OR TRAVEL WERE ACCEPTED
(e.g., that refusal of tangible gift would cause donor embarrassment or travel was consistent with interests of the
U.S.):
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
8. DATE(S) OF ACCEPTANCE (for travel, give inclusive dates travel occurred):
_________________________________________________________________________________
Signature: ______________________________________________________________
Office Address: __________________________________________________________
Date: ________________________________________________
Submit ORIGINAL form (with original signature) to:
House Committee on Ethics
1015 Longworth House Office Building
Washington, DC 20515
(202) 225-7103
Last Updated 1/2017

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