STATE-USIA

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

b. Number Of Days Already Worked For This And Other Federal Agencies During Applicable 365-days Period -----c. Total Number Of Days (sum of a. and b.)

PART II. TO BE COMPLETED BY APPOINTEE

1. FEDERAL GOVERNMENT EMPLOYMENT. List all other Federal agencies and other organizational segments of this Agency in which you are presently employed. If none, write NONE.

2. NON-FEDERAL EMPLOYMENT. Name all corporations, companies, firms, State or local Governmental organizations, research organizations, and educational or other institutions in which you are serving as employee, officer, member, owner, trustee, director, expert, adviser, 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

3. FINANCIAL INTERESTS. Nome all corporations, companies, firms, or other business enterprises in which you have any financial interest through the ownership of stock, stock options, bonds, securities, or other arrangements including trusts which relate either directly or indirectly to your duties and responsibilities as a special Government employee.

NAME OF ORGANIZATION

KIND OF ORGANIZATION

(manufacturing, storage, public utilities, etc.)

NATURE OF INTEREST AND IN
WHOSE NAME HELD

4. ACTIONS ON BEHALF OF FOREIGN PRINCIPALS. Have you ever been an agent or otherwise acted for a foreign principal under the terms of Foreign Agents Registration Act of 1939? Yes No If yes, state details.

I CERTIFY that the statements I have made are true, complete, and correct to the best of my knowledge and belief. I UNDERSTAND that if, during the period of my appointment, I undertake a new employment, I must promptly file an amended statement, and I must also report any new financial interests acquired during this period.

FORM JF-1A 8-67

(When completed, submit in sealed envelope to your Agency Counselor - Sec. 10.735-102)

CONFIDENTIAL STATEMENT OF EMPLOYMENT AND FINANCIAL INTERESTS

For use by a special Government employer

as required by section 306 of Executive
Order 11222, dated May 8, 1965, Prescribing
Standards of Ethical Conduct for Government
Officers and Employees.

GENERAL REQUIREMENTS.

The information to be furnished in this statement is
required by Executive Order 11222, the regulations of
the Civil Service Commission and the joint regulations
of the Department of State, the United States Information
Agency and the Agency for International Development,
issued thereunder and may not be disclosed except as
the agency head may determine for good cause shown.

The Order does not require the submission of any infor-
mation relating to an employee's connection with, or interest
in, a professional society or a charitable, religious,
social, fraternal, recreational, public service, civic,
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 or money from or contracts with the Government
are deemed to be "business enterprises" for purposes
of this report and should be included.

The information to be listed does not require a showing
of the amount of financial interest, indebtedness, or the
value of real property.

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 Part IV of your statement.

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

*** Submissions by the Office of the Secretary.

(1965-1975)

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