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U.S. Office of Government Ethics

OGE Optional Form 450-A (08/2005)

Confidential Certificate of No New Interests (Executive Branch)

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 “changed 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 _________________________________________________________________

For Agency Use

Date Received by Agency:

Notes:

Oge Optional Form 450-A - Confidential Certificate Of No New Interests (Executive Branch)