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to the appropriate Ethics Counselor for review and action.

APPENDIX A-1-UNITED STATES DEPARTMENT OF THE INTERIOR, U.S. GEOLOGICAL SURVEY, EMPLOYEE CERTIFICATION

PRIVACY ACT NOTICE 43 U.S.C. 31(a) and 5 U.S.C. 301 constitute the authority for requesting this certification. This certification must be signed; fail. ure to do so could be cause for denying appointment or for appropriate disciplinary action.

This certification will be used to record officially the fact that you have knowledge of, and are in compliance with, the restrictions pertinent to your employment. The information certified to 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 Civil Service Commission, the Department of Justice and to appropriate law enforcement agencies.

APPENDIX A-2–UNITED STATES DEPARTMENT OF THE INTERIOR, BUREAU OF INDIAN AFFAIRS, EMPLOYEE CERTIFICATION

I have been given a copy of Department of the Interior Regulations governing Responsibilities and Conduct of Employees (43 CFR 20.735). I have been advised of the name and location of the Bureau and Deputy Ethics Counselors. I understand that I may discuss questions or concerns related to my responsibilities, conduct, and financial interests with these individuals.

I certify I have been informed of the statutory restrictions contained in Title 43, U.S. Code, Section 31(a), which provides that employees of the Geological Survey shall have no personal or private interest in the lands or mineral wealth under survey, and shall execute no surveys or examinations for private parties or corporations.

The Department has determined that these restrictions prohibit an employee of the Geological Survey from having any personal or private interest, direct or indirect, in lands whose title is in the United States. Further, an employee of the Geological Survey is prohibited by the U.S. Code from having any personal or private interest in the mineral wealth of such lands and from executing surveys or examinations for private parties. By paragraph 20.735-13(b) of the Regulations, the Department has also prohibited an employee of the Geological Survey from having a substantial personal or private interest, direct or indirect, in any private mining or mineral enterprise doing business in the United States except where specifically authorized by the Director of Geological Survey.

I certify that to the best of my knowledge I do not have any personal or private interest, direct or indirect, in the Federallyowned lands of the United States nor in the mineral wealth of such lands.

I also certify that to the best of my knowl. edge I do not have any substantial personal or private interest, direct or indirect, in any private mining or mineral enterprise doing business in the United States except where the Director has authorized me to have such interest.

I have been given a copy of Department of the Interior Regulations governing Responsibilities and Conduct of Employees (43 CFR 20.735). I have been advised of the name and location of the Deputy or Assistnan ant Ethics Counselor for my office. I understand that I may discuss questions or concerns related to my responsibilities, conduct and financial interests with this individual.

I certify I have been informed and am in compliance with the statutory restrictions contained in Title 25 U.S.C., Section 68, (also referred to in 25 U.S.C. 68a and 441 and 25 CFR 251 and 252) which prohibits any person employed in Indian affairs in the Department of the Interior from having an interest or concern in any trade with the Indians, except for, and on account of, the United States.

I also certify I will not in the future acquire any such interest or concern in violation of the law, so long as I am employed in the Department and involved with Indian affairs.

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to the appropriate Ethics Counselor for

INSTRUCTIONS review and action.

1. All applicable employees of the Bureau PRIVACY ACT NOTICE

of Land Management shall complete the 25 U.S.C. 68 and 5 U.S.C. 301 constitute

certifications on this form. the authority for requesting this certifica

2. Signed certificates shall be sent to and tion. This certification must be signed; fail

maintained by the appropriate Ethics Counure to do so could be cause for denying ap

selor. pointment or for appropriate disciplinary 3. If an employee is unable to sign the ceraction.

tificate, he must submit a statement of facts This certification will be used to record of- to the appropriate Ethics Counselor for ficially the fact that you have knowledge of, review and action. and are in compliance with, the restrictions pertinent to your employment. The infor

PRIVACY ACT NOTICE mation certified to will be considered confi

43 U.S.C. 11 and 5 U.S.C. 301 constitute dential and will form a part of the records of the office where you file; as such the con

the authority for requesting this certificatents may be routinely disclosed to author

tion. This certification must be signed; failized auditors, the Civil Service Commission,

ure to do so could be cause for denying apthe Department of Justice and to appropri- pointment or for appropriate disciplinary ate law enforcement agencies.

action.

This certification will be used to record ofAPPENDIX A-3—UNITED STATES DEPART- ficially the fact that you have knowledge of,

MENT OF THE INTERIOR, BUREAU OF and are in compliance with, the restrictions LAND MANAGEMENT, EMPLOYEE CERTI- pertinent to your employment. The inforFICATION

mation certified to will be considered confi

dential and will form a part of the records I have been given a copy of Department of of the office where you file; as such the conthe Interior Regulations governing Respon- tents may be routinely disclosed to authorsibilities and Conduct of Employees (43 ized auditors, the Civil Service Commission, CFR 20.735). I have been advised of the

the Department of Justice and to appropriname and location of the Deputy or Assist

ate law enforcement agencies. ant Ethics Counselor for my office. I understand that I may discuss questions or concerns related to my responsibilities, conduct

APPENDIX A-4–UNITED STATES DEPARTand financial interests with this individual.

MENT OF THE INTERIOR, BUREAU OF I certify that I understand and that I am MINES, EMPLOYEE CERTIFICATION in compliance with the statutory restrictions in Title 43 U.S.C. 11, which provides: I have been given a copy of Department of

The officers, clerks, and employees in the the Interior Regulations governing ResponBureau of Land Management are prohibited sibilities and Conduct of Employees (43 from directly or indirectly purchasing or be- CFR 20.735). I have been advised of the coming interested in the purchase of any of name and location of the Deputy or Assistthe public land; and any person who violates ant Ethics Counselor for my office. I underthis section shall forthwith be removed stand that I may discuss questions or confrom office.

cerns related to my responsibilities, conduct, I also certify that neither I nor my spouse

and financial interests with this individual. has, nor is either of us in the process of acquiring, in violation of 43 CFR, Part 7, any

I certify that I have been informed of and interest, direct or indirect, in any lands or

that I am in compliance with the statutory resources administered by the Bureau of

restrictions contained in Title 30 U.S.C., Land Management.

Section 6, which prohibit employees of the I further certify I understand that if

Bureau of Mines from having any personal either I or my spouse acquires during my or private interest in any mine or the prodemployment, interest in lands or resources ucts of any mine under investigation by the administered by the Bureau of Land Man- Bureau; accepting employment from any agement, by gift, devise, bequest or oper- private party for services in the examinaation of law, that I am required to submit a tion of any mine or private mineral properstatement of facts surrounding such acquisi

ty; or issuing any report as to the valuation tion promptly through channels to my

or the management of any mine or other bureau head for transmittal to the Secre

private mineral property other than as part tary of the Interior for decision or other

of my official duties. necessary action.

(Date)

(Date)

(Signature of Employee)

(Signature of Employee)

INSTRUCTIONS 1. All applicable employees of the Bureau of Mines shall complete the certifications on this form.

2. Signed certificates shall be maintained in the Official Personnel Folder.

3. If an employee is unable to sign the certificate, he must submit a statement of facts to the appropriate Ethics Counselor for review and action.

PRIVACY ACT NOTICE 30 U.S.C. 6 and 5 U.S.C. 301 constitute the authority for requesting this certification. This certification must be signed; failure to do so could be cause for denying appointment or for appropriate disciplinary action.

This certification will be used to record officially the fact that you have knowledge of, and are in compliance with, the restrictions pertinent to your employment. The information certified to 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 Civil Service Commission, the Department of Justice and to appropriate law enforcement agencies.

lates this section shall forthwith be removed from office.

(2) Title 25 U.S.C. Section 68, (also referred to in 25 U.S.C. 68a and 41 and 25 CFR 251 and 252) which provides that any person employed in Indian affairs in the Department of the Interior is prohibited from having interest or concern in any trade with the Indians, except for, and on, account of, the United States.

(3) Title 30 U.S.C. 6, which provides that employees are prohibited from owning stock in any mine or mining company which may directly benefit by work of the Bureau of Mines through its investigations, technical research, or economic studies.

(4) Title 43 U.S.C. 31(a) which provides that employees shall have no personal or private interests in the lands or mineral wealth of the region under survey, and shall execute no surveys or examinations for private parties or corporations. The Department has determined that these restrictions prohibit personal or private interest, direct or indirect, in lands whose title is in the United States or in the mineral wealth of such lands.

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APPENDIX A-5-[RESERVED]

APPENDIX A-6-UNITED STATES DEPARTMENT OF THE INTERIOR, OFFICE OF THE SECRETARY, EMPLOYEE CERTIFICATION

INSTRUCTIONS 1. All applicable employees of the Office of the Secretary and other organizational entities reporting directly to a Secretarial officer shall complete the certifications on this form.

2. Signed certificates shall be sent to and maintained by the appropriate Ethics Counselor.

3. If an employee is unable to sign the certificate, he must submit a statement of facts to the appropriate Ethics Counselor for review and action.

I have been given a copy of Department of the Interior Regulations governing Responsibilities and Conduct of employees (43 CFR 20.735). I have been advised of the name and location of the Deputy or Assistant Ethics Counselor for my office. I understand that I may discuss questions or concerns related to my responsibilities, conduct and financial interests with this individual.

I understand that under regulations issued by the Secretary of the Interior the statutory restrictions listed below apply to me and to other employees in the Office of the Secretary and other organizational entities reporting directly to a Secretarial officer who are required to file a Statement of Employment and Financial Interest. Therefore, I certify that I understand and that I am in compliance with the following restrictions except where specifically authorized by the Secretary.

(1) Title 43 U.S.C. 11 which provides that certain employees are prohibited from directly or indirectly purchasing or becoming interested in the purchase of any of the public land, and that any person who vio

PRIVACY ACT NOTICE 5 U.S.C. 301 constitutes the authority for requesting this certification. This certification must be signed; failure to do so could be the cause for denying appointment or for appropriate disciplinary action.

This certification will be used to record officially the fact that you have knowledge of, and are in compliance with, the restrictions pertinent to your employment. The information certified to 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 Civil Service Commission, the Department of Justice and to appropriate law enforcement agencies.

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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 1. 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 1 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 'indebted by reason of a mortgage on property which you occupy as a personal residence to whom you may be indebted for current and ordinary household and living expenses su as household furnishings, automobile, education, vacation, and similar expenses. If no write NONE.

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See back of form for applicable exclusions.

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

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