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U.S. Office of Government Ethics

OGE Optional Form 450-A (08/2005)

Privacy Act Statement

Pursuant to Title I of the Ethics in Government Act of 1978 (5 U.S.C. App.) and Executive Order 12674, (as

modified by Executive Order 12731) the Office of Government Ethics regulations at 5 CFR Part 2634,

Subpart I, permit the completion of this Certificate of No New Interests in lieu of an annual OGE Form 450,

in appropriate cases.

The primary use of this form is for review by Government officials at your agency, to determine compliance

with applicable Federal conflict of interest laws and regulations. Additional disclosures of this certificate may

be made: (1) to a Federal, State, or local law enforcement agency, if the disclosing agency becomes aware

of a violation or potential violation of law or regulation; (2) to a court or party in a court or Federal

administrative proceeding if the Government is a party or in order to comply with a judge-issued subpoena;

(3) to a source when necessary to obtain information relevant to a conflict of interest investigation or

decision;(4) to the National Archives and Records Administration or the General Services Administration in

records management inspections; (5) to the Office of Management and Budget during legislative

coordination on private relief legislation; (6) to the Department of Justice or in certain legal proceedings

when the disclosing agency, an employee of the disclosing agency, or the United States is a party to

litigation or has an interest in the litigation and the use of such records is deemed relevant and necessary to

the litigation; (7) to reviewing officials in a new office, department or agency when an employee transfers

from one covered position to another; (8) to a Member of Congress or a congressional office in response to

an inquiry made on behalf of an individual who is the subject of the record; and (9) to contractors and other

non-Government employees working for the Federal Government to accomplish a function related to an

OGE Governmentwide system of records. This Certificate of No New Interests is confidential. No member of

the public shall have access to it, except as authorized by law.

Penalties

Falsification of this certificate may subject you to disciplinary action by your employing agency or other

authority. Knowing and willful falsification of the certificate may also subject you to criminal prosecution.

Oge Optional Form 450-A - Confidential Certificate Of No New Interests (Executive Branch) Page 2