Statement Of Recusal -United States House Of Representatives Committee On Ethics
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1United States House of Representatives
Committee on Ethics
Statement of Recusal
1. This is to notify the Committee that, pursuant to House Rule XXVII, I have recused myself
from any official matter that would affect the following private entity as a result of my
negotiation or agreement regarding future employment or compensation:
_________________________________________________, effective as of
___________________, 20__.
2. Pursuant to this rule, I am required to recuse myself from participation in any official matter
that will present a conflict of interest or give the appearance thereof.
3. I will promptly inform the Committee in writing if I withdraw my recusal statement.
4. For Members only: I have provided to the Clerk for public disclosure a copy of my
completed Notification of Negotiations or Agreement for Future Employment form regarding
this entity.
Signature: ______________________________________________________________
Print Name: _____________________________________________________________
Date: __________________________________________________________________
For staff, name of employing Member/committee: _______________________________
Submit ORIGINAL to:
Committee on Ethics
Office of Advice and Education
1015 Longworth House Office Building
NOTE: Forms may not be filed by fax.
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