APPENDIX B-5

UNITED STATES DEPARTMENT OF THE INTERIOR

PUBLIC DISCLOSURE STATEMENT OF KNOWN FINANCIAL INTERESTS
(Energy Policy and Conservation Act, Sec. 522, P. L. 94-163)

Form DI-211B 12-76

1. NAME (last, first, initial)

3. CALENDAR YEAR

2. TITLE OF POSITION

4. BUREAU AND OFFICE

Part I. Known Financial Interest in Businesses. You must report any pecuniary interest in any person whom you know, or could reasonably be expected to know, owns or has the right to occupy energy property or is engaged in energy business. 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

Part II. Known Financial Interests in Property. You must report any energy property you own or have a right to occupy or use. 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.

Nature of interest

Address/location of property

Privacy Act Notice: Subsection 522(a) of P. L. 94-163 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.

T

INSTRUCTIONS

1. All "covered employees" shall complete this form. These employees are responsible for reviewing and completing this form in accordance with 43 CFR 20.735-20.

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 Energy Policy and Conservation Act, 42 U.S.C. 6201, whose position has not been exempted by the Secretary of the Interior from the reporting requirements of section 522 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, who directly or through other persons subject to their control does business in any part of the United States. For purposes of this definition, the United States includes the Outer Continental Shelf.

"Energy property" means real property from which coal, natural gas or crude oil is commercially produced.

"Engaged in energy business" means the active conduct of one or more of the businesses of exploring, developing, producing, or refining, transporting by pipeline, or distributing (other than at the retail level) coal, natural gas, or petroleum products. A parent company or holding company is “engaged in energy business" if one or more of its subsidiaries in the United States is "engaged in energy business." A mutual fund or investment club is within the definition if it specializes in a business or businesses which explore, develop, refine, transport by pipeline or distribute (other than at the retail level) coal, natural gas, or petroleum products in the United States.

"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.

APPENDIX B-6

UNITED STATES DEPARTMENT OF THE INTERIOR

PUBLIC DISCLOSURE STATEMENT OF KNOWN FINANCIAL INTERESTS

(Outer Continental Shelf Lands Act Amendments of 1978, Sec. 605, P.L. 95-372) Form DI-211C

1. NAME (Last, First, Initial)

3. CALENDAR YEAR

2. TITLE OF POSITION

4. BUREAU AND OFFICE

Known Financial Interests: You must report any pecuniary interest in any person whom you know or could reasonably be expected to know (1) is applying for or has received any permits or leases authorizing exploration for or the development or production of, minerals of the Outer Continental Shelf or (2) is otherwise engaged in any business subject to the Act as amended. 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 REVERSE.

Name and kind of business

Address

Nature of known financial interests

Privacy Act Notice: Subsection 605(a) of P.L. 95-372 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....

1. TYPE OR PRINT.

INSTRUCTIONS

2. All Covered employees" shall complete this form in accordance with 43 CFR 20.735-17. 3. 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 statements (form DI-212 or DI-212A). You are cautioned that such holdings (spouse, minor children, etc.) are subject to the regular conflict of interest statutes, Executive Order, and Departmental regulations.

4. 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 as amended.

5. 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 as amended must be disclosed.

6. Signed statements shall be sent to and reviewed by your appropriate Ethics Counselor. Please retain a copy.

DEFINITIONS

"Act as amended" means the Outer Continental Shelf Lands Act, 43 U.S.C. 1331 et seq., 67 Stat. 462 as amended by the Outer Continental Shelf Lands Act Amendments of 1978, Pub. L. 95-372, September 18, 1978.

"Covered employee" means an officer or employee of the Department of the Interior performing a function or duty under the Act as amended, whose position has not been exempted by the Secretary of the Interior from the reporting requirements of Section 605 of P.L. 95-372.

"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.

"Outer Continental Shelf" means all submerged lands lying seaward and outside of the area of lands beneath navigable waters as defined in 43 U.S.C. section 1301, and of which the subsoil and seabed appertain to the United States and are subject to its jurisdiction and control.

"Mineral" means oil, gas, sulphur, geopressured-geothermal and associated resources, and all other minerals which are authorized by an Act of Congress to be produced from "public lands".

"Engaged in business subject to the Act as amended" means the conduct of any business involving the exploration for or the development or production of, minerals of the Outer Continental Shelf. A parent company or holding company is “engaged in business subject to the Act as amended" if one or more of its subsidiaries is “engaged in business subject to the Act as amended". A mutual fund or investment club is within the definition if it specializes in a business or businesses involved in the exploration for or the development or production of, minerals of the Outer Continental Shelf.

"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.

Sec.

21.6 Cabin site occupancy where a recrea-
tion or conservation area has been
leased to, or turned over to, another
Federal or non-Federal public agency
for administration.

21.7 Occupancy by trespassers.
21.8 Appeals.

AUTHORITY: Sec. 10, 32 Stat. 390; 43 U.S.C. 373; 52 Stat. 609, as amended, 43 U.S.C. 682; R.S. 2478, 43 U.S.C. 1201; 44 Stat. 471, as amended, 43 U.S.C. 869; 76 Stat. 653, 16 U.S.C. 460; 48 Stat. 402, as amended, 16 U.S.C. 664; 33 Stat. 614, 16 U.S.C. 686; 45 Stat. 448, 16 U.S.C. 690; 43 Stat. 651, 16