Please complete this form immediately upon receipt of the gift.
Send this completed form to: Property Management Services
Facilities and Administrative Services Staff
Department of Justice
National Place Building, Suite 1070
Washington, DC 20530
__________________________________________________________
(Description of Gift)
If non-cash, the value of the gift is estimated at $______________________
Note: This is a good faith estimate by the component.
This form cannot be used for gifts valued over $150.
___________________________________________________________
Employee: ___________________ Component: ______________________
Circumstances of receipt of gift:
____________________________________________________________
Donor: ______________________________________________________
Full Address: __________________________________________________
_____________________________________________________________
(Name and Signature of Component Head or designee)
(Date)
Concurrence by component Deputy Designated Agency Ethics Official (DDAEO):
_____________________________________________________________
(Name and Signature of DDAEO)
(Date)
3/18/99