APPENDIX B-2

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 Civil Service Commission, the Department of Justice and the 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 the 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 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.

Form DI-211 12-76

APPENDIX B-3

UNITED STATES DEPARTMENT OF THE INTERIOR

PUBLIC DISCLOSURE STATEMENT OF KNOWN FINANCIAL INTERESTS

(Federal Land Policy and Management Act, Sec. 313, P. L. 94-579)

1. NAME (last, first, initial)

2. TITLE OF POSITION

3. CALENDAR YEAR

4. BUREAU AND OFFICE

Known Financial Interests: You must report (1) any right to use, occupy or develop public land or mineral, timber, range, wildlife, recreation, watershed or other resources thereon, or (2) any pecuniary interest in any person whom you know, or could reasonably be expected to know, is engaged in a business subject to the Federal Land Policy and Management Act. You are under an obligation to exercise diligence in determining whether companies or other business entities in which you own interests fall in this category. Include all interests held at any time during the previous calendar year. If as of the reporting date an interest is no longer held, so indicate. If no such interests were held, write "NONE." See instructions and definitions on back of form.

Name and kind of business

Address

Nature of known financial interest

Privacy Act Notice: Subsection 313(a) of P. L. 94-579 provides for filing a statement disclosing all known financial interests. Subsection (d) provides that any officer or employee who is subject to, and knowingly violates subsection (a) shall be fined not more than $2,500 or imprisoned not more than one year, or both.

I am aware of the provisions of the law and regulations which require the filing of this statement and that such statement shall be subject to examination and available for copying, by the public upon request and subject to review by the designated Ethics Counselor in accordance with the Departmental conflict of interest regulations (43 CFR 20.735 Subpart B). 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.

I certify that the statements I have made are true, complete, and correct to the best of my knowledge and belief.

Signature and date.

INSTRUCTIONS

1. All "covered employees" shall complete this form. These employees are responsible for reviewing and completing this form in accordance with 43 CFR 20.735-18.

2. Signed statements shall be sent to and reviewed by the appropriate Ethics Counselor. 3. With respect to a blind trust, you are only required to disclose holdings of which you have actual knowledge; for example, those holdings initially committed to the blind trust, if subject to the provisions of the Act, must be disclosed.

4. You may exclude from this form any holdings owned solely by your spouse, minor child, or other relative residing in your home. This exclusion applies only to public disclosure statements and not to the regular confidential financial disclosure statement (form DI212). You are cautioned that such holdings (spouse, minor children, etc.) are subject to the regular conflict of interest statutes, Executive Order, and Departmental regulations.

5. You may also exclude holdings in mutual funds, holding companies, banks, savings and loan associations, investment clubs or regulated investment companies which do not specialize in any person or business subject to the Act.

DEFINITIONS

"Covered employee” means an officer or employee of the Department of the Interior performing a function or duty under the Federal Land Policy and Management Act, P.L. 94579, 90 Stat. 2743, whose position has not been exempted by the Secretary of the Interior from the reporting requirements of section 313 of the Act.

"Person" means an individual, corporation, partnership, association, consortium, company, firm, society, trust, joint venture, joint stock company, or any entity organized for a common business purpose, wherever situated, domiciled, or doing business.

"Public land" means any land and interest in land owned by the United States within the several States and administered by the Secretary of the Interior through the Bureau of Land Management, without regard to how the United States acquired ownership, except (i) lands located on the Outer Continental Shelf, and (ii) lands held for the benefit of Indians, Aleuts and Eskimos.

"Engaged in business subject to the Federal Land Policy and Management Act" means conduct of any business involving the use occupancy or development of public land or of mineral, timber, range, wildlife, recreation, watershed or other resources thereon. A parent company or holding company is "engaged in business subject to the Federal Land Policy and Management Act": if one or more of its subsidiaries is "engaged in business subject to the Federal Land Policy and Management Act." A mutual fund or investment club is within the definition if it specializes in a business or businesses involved in the use, occupancy or development of public lands or of mineral, timber, range, wildlife, recreation, watershed or other resources thereon.

"Pecuniary interest" means any monetary or financial interest (whether owned directly by a covered employee or held for the employee's benefit by a trustee), including, but not limited to (i) the ownership of common stock, preferred stock, bonds, debentures, warrants or a partnership share, (ii) a leasehold, rental, permit, license, right-of-way, or contract, or (iii) a pension or retirement plan, shared income or other arrangement as a result of current or prior employment or professional association.

Known Financial Interests: You must report any mining claim which you own, in whole or in part, or have the right to occupy or use; any mining activity in which, you are engaged; or any pecuniary interest which you have in any individual, corporation, partnership, association, consortium, company, firm, society, trust, joint venture, joint stock company or other entity organized for common business purpose which you know, or could reasonably be expected to know, is engaged in business subject to the Mining in the Parks Act. You are under an obligation to exercise diligence in determining whether companies or other business entities in which you own interests fall in this category. Include all interests held at any time during the previous calendar year. If as of the reporting date an interest is no longer held, so indicate. If no such interests were held, write "NONE.” See back of form for instructions and definitions applicable to filing this form.

Name and kind of business

Address

Nature of known financial interest

Privacy Act Notice: Subsection 313(a) of P.L. 94-429 provides for filing a statement disclosing all known financial interests. Subsection (d) provides that any officer or employee who is subject to, and knowingly violates subsection (a) shall be fined not more than $2,500 or imprisoned not more than one year, or both.

I am aware of the provisions of the law and regulations which require the filing of this statement and that such statement shall be subject to examination, and available for copying, by the public upon request and subject to review by the designated Ethics Counselor in accordance with the Departmental conflict of interest regulations (43 CFR 20.735 Subpart B). 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.

I certify that the statements I have made are true, complete, and correct to the best of my knowledge and belief.

Signature and date...

INSTRUCTIONS

1. All "covered employees" shall complete this form. These employees are responsible for reviewing and completing this form in accordance with 43 CFR 20.735-19.

2. Signed statements shall be sent to and reviewed by the appropriate Ethics Counselor 3. With respect to a blind trust, you are only required to disclose holdings of which you have actual knowledge; for example, those holdings initially committed to the blind trust, i subject to the provisions of the Act, must be disclosed.

4. You may exclude from this form any holdings owned solely by your spouse, mino child, or other relative residing in your home. This exclusion applies only to public disclo sure statements and not to the regular confidential financial disclosure statement (form DI 212). You are cautioned that such holdings (spouse, minor children, etc.) are subject to the regular conflict of interest statutes, Executive Order, and Departmental regulations.

5. You may also exclude holdings in mutual funds, holding companies, banks, savings and loan associations, investment clubs or regulated investment companies which do not special ize in any person or business subject to the Act.

DEFINITIONS

"Covered employee" means an officer or employee of the Department of the Interior per forming a functon or duty under the Mining in the Parks Act, P. L. 94-429, whose position has not been exempted by the Secretary of the Interior from the reporting requirements of section 13 of the Act.

"Mining claim" means any patented or unpatented mining claim within any area of the National Park System.

"Mining activity" means any exploration and assessment work, preparation of mining claims for the extraction of minerals, mining, transportation of the extracted minerals processing of the extracted minerals or reclamation of a mining claim following mining provided these activities take place, in whole or part, within the boundaries of any area of the National Park System.

"Engaged in business subject to the Mining in the Parks Act" means the conduct of a business involving the ownership of, or the right to use or occupy, a mining claim or the conduct of mining activity. A parent company is “engaged in business subject to the Mining in the Parks Act" if one or more of its subsidiaries is "engaged in business subject to the Mining in the Parks Act." A mutual fund or investment club is within the definition if it specializes in a business or businesses which own or have the right to occupy or use mining claims or conduct mining activity.

"Person" means an individual, corporation, partnership, association, consortium, company, firm, society, trust, joint venture, joint stock company, or any entity organized for a common business purpose, wherever situated, domiciled, or doing business.

"Pecuniary interest" means any monetary or financial interest (whether owned directly by a covered employee or held for the employee's benefit by a trustee), including, but not limited to (i) the ownership of common stock, preferred stock, bonds, debentures, warrants or a partnership share, (ii) a leasehold, rental, permit, license, right of way, or contract, or (iii) a pension or retirement plan, shared income or other arrangement as a result of current or prior employment or professional association.