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Nsf Form 1230a - Confidential Conflict-Of-Interest Statement For Nsf Advisory Committee Members - National Science Foundation Page 3

COMMITTEE MEMBER'S CERTIFICATION

I certify that my answers to the above questions are true to the best of my knowledge. I also understand that I must contact the NSF

official responsible for the Committee if a conflict exists or arises during my term of service. I also will not divulge any confidential

information I may become aware of during my term.

Member's Name (Please Print)

Signature

Date

CERTIFICATION BY RESPONSIBLE NSF OFFICIAL

Based on my review of this form, I certify that:

No conflicts identified.

Other actions taken (explain).

Signature

Date

Privacy Act Statement

Public Burden Information

Required by Section (e)(3) of the Privacy Act

This collection is estimated to take an average of a half hour per response, including time for reviewing the

instructions, gathering the data needed, and completing the form. Send comments regarding the burden estimate

Title I of the Ethics in Government Act of 1978 (5 U.S.C. App.), Executive Order 12674, and 5 CFR Part 2634,

or any other aspect of this collection of information, including suggestions for reducing this burden, to: Reports

Subpart I, of the Office of Government Ethics regulations require the reporting of this information before you may

Clearance Officer, NSF, 2415 Eisenhower Avenue, Alexandria, Virginia 22314; and to the Office of Management

serve on a Federal advisory committee. The primary use of the information on this form is for review by officials of

and Budget, Paperwork Reduction Project (3209-0006), Washington, DC 20503. Do not send your completed

this agency, to determine compliance with applicable Federal conflict of interests laws and regulations. This

statement to these addressees. Return your completed statement to the NSF Committee official who sent it to you.

confidential report will not be disclosed to any requesting person unless authorized by law. Failure to file this form

will preclude your service on the advisory committee. Knowing and willful falsification of information required to

be reported could subject you to criminal prosecution.

Nsf Form 1230a - Confidential Conflict-Of-Interest Statement For Nsf Advisory Committee Members - National Science Foundation Page 3