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U.S. Office of Government Ethics (OGE), Suite 500, 1201 New York Avenue, NW., Washington, DC 20005-3917 Phone: 202-482-9300, FAX: 202-482-9238 Request to Inspect or Receive Copies of SF 278 Executive Branch Personnel Public Financial Disclosure Reports or Other Covered Records OGE Form 201 (July 2006) I. Application Agency Use Only 1. Applicant’s name and address (please print): Received date: Filled date: 1a. Office telephone number: ( 2. Occupation: ) _____ ______ ext. _____ 3. If application is for or on behalf of any other person or organization, give the other's name: 3a. Address of the other person or organization: 4. Type of applicant: ❐ news media ❐ private citizen ❐ public interest group ❐ law firm ❐ other private organization ❐ government 5. ❐ Copy of the most recent (or other, specify) Public Financial Disclosure Report Form SF 278 requested for the following named individual(s): a. d. b. e. c. f. Certain other types of records ("covered records") can also be requested using this form (see Part III below); if you are requesting another covered record, check this box ❐ and specify which type of record(s): 6. Indicate how you wish to receive this request: ❐ Pick up at OGE ❐ By mail (at the address listed above) I am aware that pursuant to section 105(c) of the Ethics in Government Act of 1978, as amended and 5 C.F.R. § 2634.603(f) of the implementing OGE regulations, it is unlawful for any person to obtain or use a report: (1) (2) (3) (4) for any unlawful purpose; for any commercial purpose, other than by news and communications media for dissemination to the general public; for determining or establishing the credit rating of any individual; or for use, directly or indirectly, in the solicitation of money for any political, charitable, or other purpose. The Attorney General may bring a civil action against any person who obtains or uses a report for any such prohibited purpose as set forth above. The court may assess against such a person a penalty in any amount not to exceed $11,000. Such remedy shall be in addition to any other remedy available under statutory or common law. 7. Applicant's signature: Date: II. Notice of Action ❐ Copies of the report(s) or other covered record(s) you requested are enclosed. ❐ Picked up by (signature): Date: ❐ Your request does not comply with the requirements of the statute. Please complete Part I of this form and return so we may comply with your request. ❐ Fees. If applicable, amount: (when fees are required, make out a check payable to the U.S. Treasury and send it to the executive branch agency processing this request form). (form continued on reverse side) Clear Form Print Form Approved OMB No. 3209-0002 A. Privacy Act Statement Section 105 of the Ethics in Government Act of 1978, as amended (5 U.S.C. App.), and 5 C.F.R. § 2634.603 authorize the solicitation of the information requested in this form. The primary use of the information on this form is to permit officials of the recipient agency to consider and process your request for inspection or receipt of a copy(ies) of the SF 278 Executive Branch Personnel Public Financial Disclosure Report form(s) or other covered record(s) to which you seek access. Failure to furnish the information will result in this agency's inability to allow access to, or to provide copies of, the financial disclosure report form(s) or other record(s) requested. Otherwise, furnishing the requested information is voluntary. The information on this form itself may be publicly disclosed pursuant to proper request under section 105(b) of the Ethics Act or as otherwise authorized by law. Additional disclosures of the information on this form 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. See also the OGE/GOVT-1 executive branchwide Privacy Act system of records. B. Public Burden Information Public burden reporting for this collection of information is estimated to take approximately ten minutes per response, including time for reviewing instructions, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden,�to the Deputy Director for Administration and Information Management, U.S. Office ofGovernment Ethics, Suite 500, 1201 New York Avenue, NW., Washington DC 20005-3917. Do not file this form with this official; rather, file it with the appropriate office of the executive branch department or agency from which you are seeking access to a financial disclosure report or other covered records. Pursuant to the Paperwork Reduction Act, as amended, an agency may not conduct or sponsor, and no person is required to respond to, a collection of information unless it displays a currently valid OMB control number (that number, 3209-0002, is displayed here and in the lower right-hand corner of the front page of this OGE Form 201). III. Other Covered Records In addition to requests for access to public SF 278 reports, this form can also be used to request access to certain other agency records which are covered under the access procedures of section 105 of the Ethics Act and the implementing OGE regulations ("covered records"). Such other covered records are: (1) certificates of divestiture; (2) Ethics Act qualified blind trust and qualified diversified trust instruments (other than those provisions which relate to the testamentary disposition of the trust assets), the list of assets transferred to such trusts (and of assets sold in the case of a qualified blind trust), as well as, in the case of trust dissolution, the report thereon and the list of trust assets at that time, and the certificates of independence and compliance with respect to qualified trusts; (3) 18 U.S.C. § 208(b)(1) & (b)(3) waivers granted by the recipient agency (after deletion of any material withholdable pursuant to the Freedom of Information Act, 5 U.S.C. § 552 (see 18 U.S.C. § 208(d)(1)); (4) other OGE Form 201s; (5) cover letters for approved gifts reporting waiver requests; and (6) cover letters for approved public reporting waiver requests for certain less than 130-day special Government employees. If you seek access to any such additional record(s), check the second box in Part I.5 on the front page and specify the record(s) sought. OGE Form 201 July 2006