General Instructions. When there is insufficient space on this form to provide the required information, use back of form or attachments as necessary. If any information is to be supplied by other persons, e.g. trustee, accountant, relative, show on the form or attachment the name and address of such persons, the date you requested that information be supplied, and the nature of subject matter involved. See the back of the form for additional instructions and the Privacy Act notice.

Part I. Financial Interests. List the names of all business entities, nonprofit organizations, and educational and other institutions in which you, your spouse, minor children or other relatives who are full-time residents of your immediate household have (1) a continuing financial interest, through a pension or retirement plan, shared income, or other arrangement as a result of any current or prior employment or business or professional association; or (2) any financial interest through the ownership of stock, stock options, bonds, securities or other arrangements including trusts 1. If none, write NONE.

Name of organization

Kind of organization and address for other than listed corporations-those traded on major U.S. stock exchanges

Nature of financial interest, for stockholdings of listed corporations show number of shares. For all other financial interests show value and annual return, if applicable 2

Part II. Real Property. List interest in real property or rights (e.g. mineral, grazing) in lands, in which you, your spouse, minor children or other relatives who are full-time residents of your immediate household have an interest. Exclude property which you occupy as a personal residence. If none, write NONE.

Nature of interest, e.g., ownership, mortgage, lien, investment trust, mineral or grazing rights

Type and purpose of investment, e.g.,
residence, hotel, apartment, farm,
undeveloped land, recreation

Address and proximity to Federal lands, if Interior developed so indicate. (If rural, give RFD, or specify County and State.) 2

Part III. Employment. List the names of business entities, nonprofit organizations, and educational and other institutions' with which you are connected as an employee, officer, owner, director, member, trustee, partner, adviser, or consultant. If none, write NONE.

Name and kind of organization

Address

Position in organization

Part IV. Creditors. List the names of your creditors other than those to whom you may be indebted by reason of a mortgage on property which you occupy as a personal residence or to whom you may be indebted for current and ordinary household and living expenses such as household furnishings, automobile, education, vacation, and similar expenses. If none, write NONE.

2 Identify the ownership of interests of yourself and relatives as follows: Sole ownerships of employee (E), joint ownership with spouse, minor child or other resident relative (J), sole ownership of spouse (S), sole ownership of minor children (C), sole ownership of other relatives who are full-time residents in your household (R).

APPENDIX B-1

Instructions

Privacy Act Notice: Section 402 of Executive Order 11222 and 5 CFR 735.401 constitute the authority for collecting the personal data on this confidential statement of employment and financial interests. This data must be furnished; failure to do so could be cause for appropriate disciplinary action.

The information gathered from the statement will be used to determine whether there are any real or apparent conflicts of interest in violation of 18 U.S.C. § 201 et seq., Executive Order 11222 and 43 CFR 20.735 (Employee Responsibilities and Conduct). The information you provide will be considered confidential and will form a part of the records of the office where you file; as such the contents may be routinely disclosed to authorized auditors, the Office of Personnel Management, the Department of Justice and to appropriate law enforcement agencies.

General Requirements: You are not required to submit any information relating to any connection with, or interest in, a professional society, a charitable, religious, social, fraternal, recreational, public service, civil, or political organization or any similar organization not conducted as a business enterprise and which is not engaged in the ownership or conduct of a business enterprise. Educational and other institutions doing research and development or related work involving grants of money from or contracts with the Government are deemed to be "business enterprises" for purposes of this report and should be included. Except where Organic Act restrictions apply, either by statute or regulation (§ 20.735-12 and -13) you may exclude: (1) Holdings in widely held mutual funds, investment clubs, or regulated investment companies not specializing in a particular industry or (2) Savings or deposits in banks, credit unions, building and loan associations, or insurance companies. In the event any of the required information, including holdings placed in trust, is not known to you but is known to another person, you should request that other person to submit the information on your behalf and should report such request in your statement. This requirement may be waived for holdings in an approved blind trust (§ 20.735-24(a)(3)).

The financial and real property interest, if any, of a spouse, minor child, or other member of your immediate household shall be reported in this statement. If that information is to be supplied by others, it should be so indicated. "Member of your immediate household" includes only those relatives who are full-time residents of your household.

While employment and creditor information pertaining to your spouse, minor children or other relatives who are full-time residents of your immediate household are not reportable, you are cautioned that such activities also may create an appearance of conflict. If your official duties may bring you in contact with business entities, non-profit organizations, or other institutions with which your spouse, minor children or other relatives have either an employment or creditor relationship you should consult with your Ethics Counselor. GPO 909-76 /

80-147 0-81--15

Form DI-213

REV. 12-76

APPENDIX B-2

UNITED STATES DEPARTMENT OF THE INTERIOR

CONFIDENTIAL STATEMENT OF EMPLOYMENT AND FINANCIAL INTERESTS
(For Use by Special Government Employees)

2. Federal Government Employment-List all other Federal agencies in which you are presently employed. (If none, write "none.")

Agency and location

Appointment period

Title or kind of position

From

To

3. Non-Federal Employment-Name all corporations, companies, firms, State or local Government organizations, research organizations, and educational or other institutions in which you are serving as employee, officer, member, owner, trustee, director, expert, advisor, or consultant, with or without compensation. (If none, write “none.")

Name and kind of organization (e.g., manufacturing, research, insurance)

Location (City, State)

Title or kind of position

4. Financial Interests-List the names of all corporations, companies, firms, or other business enterprises, partnerships, nonprofit organizations, and educational, or other institutions in which you have any financial interest through the ownership of stock, stock options, bonds, securities, or other arrangements including trusts. (If none, write "none.") Interest, if any, of a spouse, minor child, or other member of your immediate household shall

be reported in this statement as your interest. Member of your immediate household includes those blood relations who are full-time residents of your household.