CONFIDENTIAL CONFLICT OF INTEREST CERTIFICATION
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Identification of Matter (Case Number, Name, etc.)
I, __________________________ hereby certify that to
the best of my knowledge, neither I nor my spouse, dependent child,
general partner, or any organization for which I am serving as an
officer, director, trustee, general partner or employee, or any person
or organization with whom I am negotiating or have an arrangement
concerning prospective employment has a financial interest in this
matter.
I further certify to the best of my knowledge that this matter will
not affect the financial interests of any member of my household.
Also, to the best of my knowledge, no member of my household; no
relative with whom I have a close relationship; no one with whom my
spouse, parent or dependent child has or seeks employment; and no
organization with which I am seeking a business relationship nor which
I now serve actively or have served within the last year are parties
or represent a party to the matter.
I also acknowledge my responsibility to disclose the acquisition of
any financial or personal interest as described above that would be
affected by the matter, and to disclose any interest I, or anyone
noted above, has in any person or organization that does become
involved in, or is affected at a later date by, the conduct of this
matter.
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Privacy Act Statement
Title I of the Ethics in Government Act of 1978 (5 U.S.C. App.),
Executive Order 12674 and 5 CFR Part 2634, Subpart I require the
reporting of this information. The primary use of the information on
this form is for review by officials of the Justice Department to
determine compliance with applicable federal conflict of interest laws
and regulations. Additional disclosures of the information on this
report may be made: (1) to a federal, state or local law enforcement
agency if the Justice Department becomes aware of a violation or
potential violation of law or regulations; (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;
and (6) in response to a request for discovery or for the appearance
of a witness in a judicial or administrative proceeding, if the
information is relevant to the subject matter. This confidential
certification will not be disclosed to any requesting person unless
authorized by law. See also the OGE/GOVT-2 executive branchwide
Privacy Act system of records.