Oge Form 450 - Executive Branch Confidential Financial Disclosure Report Page 6
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7OGE Form 450, 5 CFR Part 2634, Subpart I
Form Approved:
U.S. Office of Government Ethics (2/96)
OMB No. 3209-0006
Executive Branch CONFIDENTIAL FINANCIAL DISCLOSURE REPORT
Position/Title
Grade
Reporting Status:
Employee's Name (Last, first, middle initial)
New entrant
Annual
Work Phone
If New Entrant, Date of Appointment
Agency
Branch/Unit and Address
If an SGE, Home Address (Number, Street, City, State and ZIP Code)
Check box if special Government
employee (SGE)
I certify that the statements I have made on this form and all attached
Signature of Employee
Date
statements are true, complete, and correct to the best of my knowledge.
Date Received by
On the basis of information contained in this report, I
Signature and Title of Supervisor/Other Intermediate Reviewer (If agency requires)
Date
Agency
conclude that the filer is in compliance with applicable laws
and regulations (except as noted in "comments" box below).
Signature of Agency's Final Reviewing Official and Title
Date
Comments of Reviewing Officials
(Check box if continued
on reverse)
Part I: Assets and Income
Assets and Income Sources (Identify specific employer, business, stock, bond,
Nature of Income over $200 (Rent, interest,
(X) if no
Date (Only
dividends, capital gains, salary, etc.)
mutual fund, type/location of real estate, etc.)
longer held
for honoraria)
None
Rental Condo, Anchorage, Alaska
Rent
Dee, Jones & Smith, Hometown, USA
X
Salary
Examples
Identify for you, your spouse, and depen-
(S)
Alexandria Medical Clinic, Alexandria, VA
Salary
dent children: 1) assets with a fair market
Franklin Equity Mutual Fund
Dividends/Capital Gains
value greater than $1,000 at the close of the
reporting period or producing income over
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$200; and 2) sources of earned income such
as salaries, fees, honoraria (other than U.S.
Government salary or retirement benefits,
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such as the Thrift Savings Plan) which gen-
erated over $200 in income during the re-
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porting period. Earned income sources of
your spouse must be reported if greater than
$1,000 (greater than $200 for honoraria).
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No earned income needs to be reported for
dependent children.
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Assets include (but are not limited to): stocks,
bonds, tax shelters, real estate, mutual funds,
pensions, annuities, IRAs, trusts, commod-
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ity futures, trades and businesses, and part-
nership interests.
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Exclude your personal residence, unless you
rent it out, and deposit accounts in financial
institutions. See instructions for additional
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exclusions.
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Use copies of blank pages
for continuation
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