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415892631
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[Executive Personnel Financial Disclosure Form]
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415892631
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[Executive Personnel Financial Disclosure Form]
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13894-011
collections
Records of the White House Office of Speechwriting (George H. W. Bush Administration)
Tony Snow Subject Files
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Originally Processed With FOIA(s):
FOIA Number:
S
FOIA
MARKER
This is not a textual record. This is used as an
administrative marker by the George Bush Presidential
Library Staff.
Record Group/Collection: George H.W. Bush Presidential Records
Collection/Office of Origin:
Speechwriting, White House Office of
Series:
Snow, Tony, Files
Subseries:
Subject File, 1988-1993
OA/ID Number:
13894
Folder ID Number:
13894-011
Folder Title:
[Executive Personnel Financial Disclosure Form]
Stack:
Row:
Section:
Shelf:
Position:
G
18
29
2
2
A basic premise of the statutory financial dis-
II. Who Must File
or Vice President or by May 15 of that calendar
Executive Personnel
closure requirements is that those having respon-
a. Candidates for nomination or election to the office
year, whichever is later, and on or before May 15
Financial Disclosure
sibility for review of reports filed pursuant to the Act
of President or Vice President.
of each succeeding year that such an individual
or permitted public access to reports, must be giv-
continues to be a candidate on such date.
Report
en sufficient notice by reporting individuals in their
b. Presidential nominees to positions requiring the ad-
reports concerning the nature of their outside in-
vice and consent of the Senate, other than those
b. Within 5 days after the transmittal by the Presi-
dent to the Senate of the nomination of an in-
Instructions for Completing SF 278
terests and activities so that an informed judgment
nominated for judicial office or for appointment to a
rank in the uniformed services at a pay grade of 0-6
dividual referred to in section II(b) of these
can be made with respect to the individuals' com-
or below.
instructions or, prior to that time, at any time af-
pliance with applicable conflict of interest laws and
ter the President or President-elect has publicly
standards of conduct regulations. Therefore it is im-
C. The following newly elected or appointed officials:
announced his or her intention to nominate the
Privacy Act Statement
portant that you carefully complete the attached
The President;
individual.
The Ethics in Government Act of 1978, as amend-
form. This report is a safeguard for you as well as
The Vice President;
ed, 5 U.S.C. App. §201 et seq, requires the report-
the Government in that it provides a mechanism for
C. Within 30 days after assuming a position
determining actual or potential conflicts between
Officers and employees (including special Govern-
described in section II(c) unless such an individual
ing of this information. This information will be
your public responsibilities and your private interests
ment employees, as defined in 18 U.S.C. §202)
has left another position described in section II(c)
reviewed by Government officials to determine com-
and activities and allows you and your agency to
whose positions are classified at GS-16 or above
within 30 days prior to assuming the new posi-
pliance with applicable Federal laws and regulations,
fashion appropriate protections against such con-
of the General Schedule, or whose basic rate of
tion, or has already filed a report with respect to
and the report may be disclosed upon request to any
requesting person pursuant to section 205 of the Act
flicts when they first appear.
pay (excluding "step" increases) under other pay
nomination for the new position (section II(b)) or
schedules is equal to or greater than the rate for
as a candidate for the position (section II(a)).
or as otherwise authorized by law. You may inspect
Definitions and Terms
GS-16 (step 1) (a group which includes all mem-
d. No later than May 15 annually, in the case of
applications for review of your own form upon re-
quest. Knowing or willful failure to file or report in-
Category of Amount
bers of the Senior Executive Service);
those in a position described in section II(C). In
formation required to be reported by section 202 of
Reportable financial interests are disclosed either
Members of the uniformed services whose pay
the event such an individual terminates employ-
by exact amount or by category of amount, de-
grade is 0-7 or above;
ment, and does not accept another position
the Act (or falsification) may subject you to a civil
penalty of not more than $5,000 and to disciplinary
pending on the interest as shown in the form. You
Officers or employees in any other position de-
described in section II(c), the report must be filed
action by your employing agency or other appropri-
may, but you are not required to, indicate an ex-
termined by the Director of the Office of Govern-
no later than the 30th day after termination.
ate authority. Knowing or willful falsification of in-
act amount where the form provides for a cate-
ment Ethics to be of equal classification to GS-16;
IV. Where to File
formation required to be filed by section 202 of the
gory of amount or value.
Administrative law judges;
Act may also subject you to criminal prosecution un-
Dependent Child
Employees in the excepted service in positions
a. Candidates for President and Vice President, with
der 18 U.S.C. $ 1001, leading to a fine of not more
The term "dependent child" means your son,
which are of a confidential or policy-making
the Federal Election Commission.
than $10,000 or imprisonment for not more than five
daughter, stepson, or stepdaughter if such per-
character, unless their positions have been exclud-
b. The President and Vice President, with the Of-
years or both.
son is either: (i) unmarried, under age 21, and liv-
ed by the Director of the Office of Government
fice of Government Ethics.
ing in your household, or (ii) a "dependent" of
Ethics;
C. Members of a uniformed service, with the Serv-
I. Introduction
yours within the meaning of section 152 of the In-
The Postmaster General, the Deputy Postmaster
ice Secretary concerned.
ternal Revenue Code of 1954.
General, each Governor of the Board of Gover-
Scope of Disclosure
Value
d. All others, with the designated agency ethics offi-
nors of the U.S. Postal Service and officers or em-
The term "value" generally means a good faith
cial at the agency in which the individual is em-
The extent of the reporting requirement is noted
ployees of the U.S. Postal Service or Postal Rate
in each schedule. The applicable reporting periods
estimate of the dollar value if the exact value is
ployed or in which he or she will serve.
Commission whose basic rate of pay is equal to
and a description of who must complete each sched-
neither known nor easily obtainable by you. When
e. In the case of individuals appointed by or to be
or greater than the minimum rate of basic pay
ule and part are described on page 1 of the form.
valuing assets, you may use a number of methods
nominated by the President to positions requir-
fixed for GS-16 (step 1); and
In addition to your separate financial information,
in addition to a good faith estimate. These are
ing confirmation of the Senate, see 5 CFR
The Director of the Office of Government Ethics
you are required to report information concerning
specifically set forth in the instructions under
734.604(c) for expedited procedure.
your spouse and dependent children in several
Schedule A.
and each designated agency ethics official.
schedules of the form. However, no report is re-
d. Incumbent officials holding positions referred to in
V. General Instructions
Relative
quired with respect to your spouse if he or she is
The term "relative" means an individual who is
section II(c) of these instructions if they have served
a. This form consists of the front page and four
living separate and apart from you with the inten-
your father, mother, son, daughter, brother, sis-
61 days or more in the position during the preced-
Schedules. You must complete each Part of all
tion of terminating the marriage or providing for per-
ter, uncle, aunt, great aunt, great uncle, first cous-
ing calendar year.
Schedules. If you have no information to report
manent separation. In addition, no report is required
in, nephew, niece, husband, wife, grandfather,
e. Certain individuals who perform staff functions in sup-
in any Part of a Schedule, you should indicate
with respect to any income or obligations of an in-
grandmother, grandson, granddaughter, father-
port of an advisory committee composed in whole
"None". A report is considered incomplete if any
dividual arising from the dissolution of a marriage
in-law, mother-in-law, son-in-law, daughter-in-law,
or in part of special Government employees (see 5
Part of any Schedule is left blank. Schedule A
or the permanent separation from a spouse. There
brother-in-law, sister-in-law, stepfather, step-
C.F.R. §734.202(h).
combines a report of income items (other than
are other exceptions to the reporting of assets and
mother, stepson, stepdaughter, stepbrother, step-
income, transactions, and liabilities of a spouse or
III. When to File
from current employment by the United States
sister, half brother, half sister, your spouse's
Government) with the disclosure of property in-
dependent child which are discussed in the instruc-
grandfather or grandmother or your fiance or
a. Within 30 days after becoming a candidate for
terests (generally referred to here as assets).
tions applicable to those subjects.
fiancee.
nomination or election to the office of President
Schedule B deals with transactions in real prop-
OFFICE OF PERSONNEL MANAGEMENT
erty or certain other assets, as well as gifts and
have to report the day-to-day transactions of the
line to the right. However, when you have a num-
A personal residence from which no income is de-
reimbursements. Schedules C and D relate to lia-
pool services business nor such things as the nor-
ber of different kinds of financial arrangements and
rived should not be reported as a property interest
bilities and employment relationships. After com-
mal and customary temporary liabilities it incurs
transactions involving one entity, a full disclosure
because it is not held for investment or production
pleting the first page and each part of the
with its suppliers.
of all the required information for that entity may re-
of income. However, if you hold residential proper-
Schedules (including extra sheets of any Sched-
f. If you need assistance in completing this form,
quire more than one line. You may always use more
ty which is used for investment or income purposes,
ule where continuation pages are required for any
contact the designated agency ethics official of
than one line for clarification if you choose.
such as a summer home rented during parts of the
part), consecutively number all pages.
the agency in which you serve, will serve or have
Note: Specific regulations for the reporting of inter-
year, you must report that interest.
b. The information to be disclosed is only that which
served.
ests in property and income are found in
In the case of personal property such as antique
the Ethics in Government Act of 1978, as amend-
5 CFR 734.301(a) and (d).
collections and related holdings, the Office of
ed, and 5 CFR Part 734 specifically require. You
Government Ethics deems intermittent sales from
may, however, include in any section of the form
Schedule A
such additional information, beyond the Act's re-
II. Property Interests and Assets
such a collection or holdings to demonstrate that
they are held for investment or the production of
quirements, as you may wish to disclose for pur-
poses of clarification.
I. General Instructions
(BLOCKS A and B)
income.
Two of the general disclosure requirements of the
A. Items to Report
C. Combine on one form the information applicable
Valuation Method
to yourself, your spouse and dependent children;
Act concern certain interests in property (generally
Report the identity and category of valuation of
any interest in property (real or personal) held by
The statute provides several methods you may use
or if more convenient, use separate schedules to
referred to here as assets) and items of income.
report the required information applicable to fa-
Schedule A is designed to enable you to meet both
you, your spouse or a dependent child, in a trade
for determining valuation:
or business, or for investment or the production
Option 1-any good faith estimate of the value of
mily members. You may, if you desire, distinguish
of these reporting requirements. Generally a de-
of income which has a fair market value which ex-
the property if the exact value is unknown
any entry for a family member by preceding the
scription of your, your spouse's or dependent child's
entry with an (S) if it is for a spouse or a (DC) if
assets and sources of income is required to be list-
ceeds $1,000 as of the close of the reporting peri-
or not easily obtainable;
od. These interests include, but are not limited to,
Option 2-value based upon a recent appraisal of
it pertains to a dependent child.
ed in BLOCK A of the Schedule. Reading from left
stocks, bonds, pension interests and annuities, fu-
the property interest;
d. Definitions of the various terms used in these in-
to right across the page from each description of the
asset or income source, you will be able to report
tures contracts, mutual funds, IRA assets, tax
Option 3-the date of purchase and the purchase
structions and detailed information as to what is
in BLOCK B the value of each asset, and in BLOCK
shelters, beneficial interests in trusts, income-
price of your interest;
required to be disclosed are contained in 5 CFR
C the type and amount of income generated by that
producing bank accounts, real estate, commercial
Option 4-the assessed value of the property for tax
Part 734.
asset or received from the non-asset source. BLOCK
animals, crops and collectibles held for the produc-
purposes adjusted to reflect current
e. In the case of references to entities which do not
D is a question designed to lead incumbents and
tion of income. Exceptions: Exclude your personal
market value if the tax assessment is
have listed securities or are not described in stan-
termination filers to Schedule B for certain of the
residence and any personal liability owed to you,
computed at less than 100% of current
dard reference materials (such as Moody's Manu-
items they have listed in BLOCK A.
your spouse or dependent child by a relative. Ex-
value (if Option 4 is used, describe the
als)-whether such entities are operating trades
clude also any deposits aggregating $5,000 or less
manner in which you adjusted the as-
or businesses, or private investment pools or oth-
On Schedule A are two examples which are rep-
in a personal savings account in a single financial
sessed value);
er private vehicles (such as IRA's) which are
resentative of the reporting scheme of this Sched-
institution. A personal savings account includes a
ule. The first example represents the proper meth-
Option 5-the year-end book value of non-publicly
themselves the media for indirect financial in-
certificate of deposit or any other form of deposit in
terests in trades or businesses attributable to you
od of reporting a stock of the XYZ Company held
traded stock, or the year-end exchange
a bank, savings and loan association, credit union
for purposes of the application of Federal law-
by the reporting individual at the end of the report-
value of corporate stocks, or the face
or similar institution. With respect to assets of a
ing period which then had a value of $40,000. The
value of corporate bonds, or comparable
you must provide sufficient information about
spouse or a dependent child, do not report items:
these private entities to give reviewers of dis-
individual had also received dividends of $1,500 and
securities;
(i) which represents your spouse's or dependent
had purchased the stock during the reporting peri-
Option 6-the net worth of your interest (as in a busi-
closure reports an adequate basis for the conflicts
child's sole financial interest or responsibility
analysis required by the Act. Thus, except in the
od. The second example represents the proper
and of which you have no knowledge;
ness partnership or other jointly held
method of reporting the source of $50,000 of earned
business interest);
case of private investment vehicles (for which full
(ii) which are not in any way, past or present, de-
disclosure of holdings is required), you must dis-
income from private law practice as well as the
Option 7-the equity value of your interest (as in a
close the primary trade or business of private en-
$12,500 the reporting individual maintained in the
rived from your income, assets, or activities;
solely owned business or commercial
capital account in the law firm at the end of the
and
tities, as well as attributed interests and activities
enterprise); and
not solely incidental to such a primary trade or
reporting period. If, in the first example, the XYZ
(iii) from which you neither derive, nor expect to
Option 8-actual value (e.g., savings accounts) or
business. For instance, if your family swimming
stock had been sold rather than purchased, there
derive, any financial or economic benefit.
any recognized indication of value (such
pool services corporation incurs a liability to pur-
would be no entry in BLOCK B because the individu-
Note: It is very difficult for most individuals to meet
as last sale on a stock exchange).
chase an apartment house for investment in ad-
al no longer owned the stock at the end of the report-
all three parts of this test, especially (iii). For
ing period, but there would be an entry for capital
You need not disclose which methods you chose un-
dition to its pool services business, you will have
instance, if you file a joint tax return with your
to report your indirectly allocable share of the cor-
gains as well as dividends in BLOCK C if they were
less you wish. This is a change from prior forms.
spouse, you derive a financial or economic
poration's liability, the apartment house invest-
realized during the period.
benefit from the items involved and you are
ment, and its purchase, in addition to the items
Normally you will have to list an item only once
charged with knowledge of those items.
B. What to Show on the Form
you are required to report about your interest in
in BLOCK A with all other value and income infor-
Therefore, those asset and income items do
Enter the identity of the asset in BLOCK A and
the family corporation. You would not, of course,
mation associated with that item shown on the same
not fit the test.
then show the applicable value in BLOCK B. Only
the category of value, rather than the actual val-
out further disclosure of what financial interests are
disclose the assets unless it is an "excepted trust"
"Honoraria"; under ACTUAL AMOUNT
ue of the property interest or asset, must be
attributable to the individual by virtue of the IRA, it
discussed immediately above.
"$1,000", and under DATE "3/19/84".
If
the
shown.
is not possible to evaluate the individual's compli-
Except for one of the three trusts described above,
same item of income was received under the
For assets such as stocks, bonds, and securi-
ance with applicable laws and regulations. If the IRA
you must identify each individual investment hold-
same circumstances by your spouse, who is self-
ties, report any holdings by you, your spouse or
were invested solely in a mutual fund such as "Tem-
ing of a trust which had a value in excess of $1,000.
employed as a marketing consultant, you would
dependent child from one source totaling more than
pleton World Fund, Inc." and the investment was
For example, in BLOCK A an entry such as "trust
enter in BLOCK A "S" Chicago Civic
$1,000 in value. Identify the holding and show the
disclosed in Schedule A, that would be sufficient,
held by First National Bank (Boston, MA) consist-
Club, 18 Lakeshore Dr., Chicago, IL"; in BLOCK
category of value. When identifying shares of pub-
as that fund's portfolio is detailed in Moody's Bank
ing of ITT stock, U.S. Treasury certificates, and Dal-
C under OTHER specify "Honoraria"; under
licly traded stocks, the common abbreviation of the
and Finance Manual and could be evaluated. If,
las Municipal Bonds" might be made. In BLOCK B
ACTUAL AMOUNT leave a blank or fill in N/A; and
name of the corporation may be used. If you have
however, the IRA was privately invested, detailed
the applicable value of each trust asset would be
under date "3/19/84". Honoraria received and
stock interests through an investment trust or mutual
disclosure of the investment would be required on
entered. (And, as described under IV B 5. Trust In-
donated to charity must be reported, but a nota-
fund, and the holdings of the trust or fund are a mat-
Schedule A in the same amount of detail as if the
come, below, the income from each asset would be
tion explaining that fact may be included in report-
ter of public record, you may-instead of identify-
investment were directly held.
entered in BLOCK C as well as income from assets
ing such items.
ing the fund's share holdings-identify your interest
of the trust sold during the reporting period.)
2. OTHER INCOME-Means all income, exclusive
by simply giving the name of the trust or mutual fund.
b. Trusts
of honoraria, received from non-investment
If you hold different types of securities of the same
With respect to trusts in which a beneficial in-
III. Earned and Other
sources including fees, commissions, salaries, in-
corporation (e.g., bonds and stocks of "X" Corpo-
terest in principal or income is held, report trust
come from personal services, pensions, etc. Re-
ration), these holdings should be considered as be-
interests and trust assets which had a value in
Non-Investment Income
port the identity of the source and give the
ing from the same source for purposes of
excess of $1,000. You need not report the identity
(BLOCKS A and C)
actual amount of such income. For example,
determining whether the aggregate value of the in-
of assets of a trust of which you are the beneficiary
A. Items to Report
if you earned $450 teaching at a law school, en-
terest is below or above the $1,000 value.
if the interest is:
For yourself, report the identity of the source in
ter in BLOCK A John Jones Law School,
To report interersts in a business, a partner-
i. a "qualified blind trust" or "qualified diversi-
BLOCK A and amount in BLOCK C of non-
Rockville, MD"; in BLOCK C under OTH-
ship, or joint venture, or the ownership of prop-
fied trust", which has been certified by the Of-
investment income exceeding $100, from any one
ER "Salary"; and under ACTUAL AMOUNT
erty held for investment or the production of
fice of Government Ethics, or
source, other than income from the United States
"$450". Exclude income totaling less than
income, identify the character of your ownership
ii. an "excepted trust", that is, one which-
Government for current Government services. Such
$100 from any one source. For example, if you
interest, and, unless a publicly traded security,
income includes fees, salaries, commissions, com-
earned $75 for teaching in one law school and
A. was not created by you, or your spouse or
the nature and location of the business or in-
dependent children, and
pensation for personal services, pension payments,
$150 from teaching at another school, report only
the $150 amount.
terest. Thus, in the case of non-publicly traded secu-
B. the holding or sources of income of which
honoraria, etc. Report these items on the same line
rities, show the nature and address of the business
you, your spouse and dependent children
as any related interest in property (if any).
If your spouse has earned income in excess
(in addition to its name). For example, the entry for
have had no knowledge.
For your spouse, report the source, but not the
of $1,000 from any one source identify the
a holding of farm land might show, under BLOCK
amount, of your spouse's non-investment income
source but show nothing under amount. If your
A
"sole ownership of 100 acres of unimproved
In such cases, in lieu of disclosing the source and
assets of the trust, you should show in BLOCK A
exceeding $1,000 from any one source. No report
spouse is self-employed in a business or profes-
dairy farm land on Rural Route # at Pine Bluff,
of the earned or non-investment income of your de-
sion, for example as a practicing psychologist who
Madison County, Wisconsin".
the identity of the trust including the date the trust
pendent children is required.
earned $10,500 during the year, you need only
was created, and the classification of the trust in-
show
under
BLOCK
A
In the case of holdings that are essentially non-
practicing
psycholo-
terest as a "qualified blind trust", a "qualified diver-
public such as private trades or businesses, invest-
sified trust", or an "excepted trust". Although you
B. What to Show on the Form
gist".
ment pools or other private investment vehicles,
need not report the identity of the assets of a
1. HONORARIA-Means payment of money or any-
3. UPDATE-A Presidential nominee to a position
sufficient disclosure must be made to give review-
qualified or excepted trust, the category of
thing of value to you or your spouse, for an ap-
requiring the advice and consent of the Senate
ers an adequate basis for the conflicts analysis re-
amount of the trust income, if it exceeded $100,
pearance, speech, or article. (See 2 U.S.C. 444i
shall file with the Senate committee considering
quired by the Act. Therefore, you must disclose the
must be reported in BLOCK C.
for full definition.) For each honorarium you
his or her nomination a report which shall update
primary trade or business of private entities, as well
received in excess of $100 show the identity of
all items of his or her earned income and honorar-
as interests and activities not solely incidental to
Note: You are not permitted by the statute to
"create" an excepted trust by avoiding pre-
the source in BLOCK A, the date and net
ia through the period ending no earlier than 5 days
such a trade or business. For example, if your fa-
amount in BLOCK C. For your spouse, you must
before the scheduled date of the Senate commit-
mily is involved in a private real estate investment
vious sources of knowledge upon entering
Government service. See subpart D of 5 CFR
show only the source of any honorarium over
tee hearing on the nomination. This update shall
business but as a side interest buys stock through
Part 734.
$1,000 and the date of the event for which it was
be provided in the manner requested by the
the business in a bank, you must disclose in addi-
received. List each honorarium separately. For ex-
Senate committee considering the nomination.
tion to real estate, (by type and general location),
It is not necessary to identify those assets of a
ample, if you received $1,400 for a speech be-
that the family business holds an interest in a bank.
trust of which a spouse or dependent child is a ben-
fore the Chicago Civic Club on March 19, 1984,
IV. Investment Income
In addition, while under the general rules of Sched-
eficiary if the trust meets the same three part test
of which $200 was actually spent for round-trip
(BLOCK C)
ule A an individual who directly holds an IRA (In-
set forth in the first paragraph under II.A. above.
travel, and $200 went to the agent who made the
Report items of investment income on the same
dividual Retirement Account) would have to indicate
However, in applying the test, if the trust is one set
speaking arrangement, enter in BLOCK A
line of Schedule A as the related property interest
its value and the income derived from it (even though
up for the education of your minor children, you do
"Chicago Civic Club, 18 Lakeshore Dr., Chica-
or other asset from which such income is derived.
non-taxable for Federal income tax purposes), with-
receive a financial benefit from such a trust and must
go, IL"; in BLOCK C under OTHER specify
Note that some property interests or other assets
will not have a related item of realized income. In
example, if you received $2,000 as rental income
the trust is a qualified trust or an excepted trust,
or exchange of any real property, stocks, bonds,
such a case, check "None (or less than $101)" in
from an apartment building in Miami, Florida,
in BLOCK A show only the identity of the trust in-
commodities futures and other securities by you,
BLOCK C under category of amount.
enter in BLOCK A "apartment building, at
cluding the date the trust was created, and in
your spouse or dependent child when the amount
5802 Biscayne Blvd., Miami, FL", and in BLOCK
BLOCK C check the classification of the trust in-
involved in the transaction exceeded $1,000. This
A. Items to Report
C check that rental income was received and
terest as a "qualified blind trust", "qualified diver-
will include the transaction for any asset for which
Report the identity in BLOCK A and category of
check the appropriate category of amount.
sified trust", or "excepted trust", and check
you answered "Yes" in BLOCK D of Schedule A.
value in BLOCK C of any investment income over
3. INTEREST-Identify the source and the
category of amount of the income realized.
It also includes reporting any sale or exchange of
$100 from any one source received by you, your
category of amount of any interest earned or
6. OTHER INVESTMENT INCOME-Report any
an asset involving an amount exceeding $1,000
spouse or dependent child, or which accrued to the
received by you, your spouse or dependent
items of investment income exceeding $100
when the sold or exchanged asset did not yield in-
benefit of any one of you during the reporting peri-
child as income from investment holdings includ-
which are not described above, such as income
come of more than $100 (and therefore was not
od. For purposes of determining whether you meet
ing: bills and notes, loans, promissory notes, an-
from business interests, property dealings, annui-
reported on Schedule A), or reporting the purchase
the over $100 threshold from any one source, you
nuity funds, bonds, and other securities. For
ties, an estate, or a distributive share of a part-
of an asset involving an amount exceeding $1,000
must aggregate all types of investment income from
example, if you earned $300 in interest during the
nership or joint business venture's income. To
but at the end of the reporting period having a value
that same source.
calendar year on a Savings Certificate with Fed-
identify the sources of other investment income,
less than $1,000 and earning income of $100 or less
Investment income includes, but is not limited to:
eral Savings and Loan, enter in BLOCK A "Fed-
either for yourself, your spouse, or a dependent
during the reporting period (and therefore not ap-
income derived from dealings in property, interest,
eral Savings and Loan (Baltimore, MD)-Savings
child, briefly characterize, in BLOCK A, the na-
pearing on Schedule A). The example on the form
rents, royalties, dividends, annuities, income from
Certificate", and in BLOCK C check that interest
ture of the business or investment interest, and
shows the proper way to disclose the XYZ common
endowment contracts, income from discharge (for-
income was received and check the appropriate
when applicable, the location: for exam-
stock the reporting individual purchased for $35,000
giveness) of debts owed to you, your distributive
category of amount.
ple
"one-third ownership in a retail furniture
on 2/1/83. Note on Schedule A, that there is an en-
share of partnership or joint venture income, and in-
store at 1010 Grand Ave., Chicago, IL". In BLOCK
try for the stock as well since it was still held at the
4. CAPITAL GAINS-Report income from capital
come from an interest in an estate or trust. You need
C, under OTHER specify the applicable type of
end of the reporting period and that the reporting
gains received or realized by you, your spouse
not show the exact dollar amount of dividends, rents
income, for example 'distributive share" from
individual properly noted "Yes" in BLOCK D.
or dependent child from sales or exchanges of
and royalties, interest, capital gains, and certain trust
a partnership or "gross income" from a
property, business interests, partnership interests
You need not report a transaction involving (1)
income. For these specific types of income you need
proprietorship, and under ACTUAL AMOUNT the
or shared ownership investment interests. Iden-
your personal residence(s); (2) a money market
only check the category of amount of the item report-
actual amount of such income which was realized
ed. For all "other investment income" as described
tify the source and check the category of
mutual fund or personal bank account; (3) an asset
during the reporting period.
amount of the gain. An example of an entry in
of your spouse or dependent child if the asset meets
in item 6 below, you will have to report the exact
BLOCK A might be "sale of one-third interest in
V. Transactions Test
the three-part test set forth under the instructions
dollar amount of income from each source.
100-acre farm in Hamilton County, lowa" and in
for Schedule A, at II.A.; and (4) a holding of a "quali-
(BLOCK D)
B. What to Show on the Form
BLOCK C check that capital gains were received
fied blind trust", a "qualified diversified trust" or an
and check the appropriate category of amount.
BLOCK D is to be completed by incumbent and
"excepted trust". You will need to report any trans-
1. DIVIDENDS-Show in BLOCK C the category of
termination filers only. It is designed to assist you
actions of a business or commercial enterprise in
the amount you, your spouse or dependent
5. TRUST INCOME-Report the category of
in determining which assets in BLOCK A will also
which you, your spouse or dependent child have a
child received as dividends from investment
amount and the type of any income of $100 or
have to be reported in Part I of Schedule B as be-
direct proprietary or general partnership interest.
sources including: common and preferred secu-
more received from any trust. You need not iden-
ing purchased, sold or exchanged during the report-
rities, endowment contracts, and pension and an-
tify the source from which the trust received the
ing period. You will need to check "YES" or "NO"
You are required to report any covered transac-
nuity funds. Identify the source of such income
income when the trust is: (i) a "qualified blind
in BLOCK D for any real property or stocks, bonds,
tion of any company, investment pool, or other en-
and check the category of amount. When iden-
trust" or "qualified diversified trust", which has
commodities futures, and other forms of securities
tity, in which you, your spouse or dependent child
tifying the source of a corporate stock dividend,
been certified by the Office of Government Ethics;
listed in BLOCK A. You need not answer the ques-
have an interest if (i) the entity is not described in
you may abbreviate the corporate name. For ex-
or (ii) an "excepted trust", one which was not
tions for any other kinds of items listed in BLOCK
standard reference materials, or (ii) the transaction
ample, if cash dividends of $950 were received
created directly by, and about which no knowl-
A. If you answer "Yes" for any such item, you must
is not incidental to the primary trade or business of
for shares of common stock of International Busi-
edge of holdings or source of income of the trust
also report the details of the purchase, sale or ex-
the entity as indicated by you on Schedule A. (See
ness Machines, enter in BLOCK A
"IBM
com-
is possessed by you, your spouse or dependent
change in Part I of Schedule B.
also section V(e) of the General Instructions preced-
mon", and in BLOCK c check that dividend in-
child. Note, you are not permitted by the statute
ing those for Schedule A.)
come was received and check the appropriate
to "create" an excepted trust by avoiding previ-
B. What to Show on the Form
category of amount.
ous sources of knowledge upon entering Govern-
Schedule B
Under identification of assets, identify the property
2. RENTS AND ROYALTIES-Show income re-
ment service. See subpart D of 5 CFR Part 734.
or securities involved in the purchase, sale or ex-
ceived by you, your spouse or dependent child
Whenever you are required to identify the
I. Part I-Transactions
change, and give the date of the transaction. For
as rental or lease payments for occupancy or use
source of trust income, either for yourself or for
example, under IDENTIFICATION OF ASSETS
of personal or real property in which any one of
a spouse or child, it is not enough simply to say
A. General Instructions and
"GMC common stock"; under TYPE OF TRANS-
you have an interest. In addition, show payments
"John Jones Trust". Generally, the investment
ACTION
received from such interests as copyrights, royal-
holdings of the trust, discussed above under
Items to Report
check type; under DATE
enter date
transaction occurred; under AMOUNT OF TRANS-
ties, inventions, patents, and mineral leases or
"Property Interests and Assets", and the income
This part is to be completed by incumbents and
ACTION
check the category of value of the sale
other interests. Identify the source of such in-
derived from each holding must be identified to
termination filers only. Give a description, the date,
price, purchase price, or exchange value of the
come and check the category of amount. For
the same extent as if held directly. However, if
and the category of amount of any purchase, sale,
property involved in the transaction.
II. Part II-Gifts and
in value received from any one source (for
ue from any one source, other than excluded gifts
must disclose the highest amount owed on any lia-
Reimbursements
purposes of the $100 aggregation in this ex-
which you or your spouse received during the
bility held during the reporting period, not just at
clusion, you need not count any items with
calendar year. Thus, if you and your spouse each
the end of the period. If the liability was completely
A. General Instructions
a fair market value of $35 or less, nor any item
receive a $60 figurine from the same donor, the
paid during the period, you may also note that on
for which, in an unusual case, a publicly avail-
gift has a value of more than $100, and it must
This Part is to be completed by incumbents and
the form if you wish.
able request for waiver was granted);
termination filers only. The Act requires you to dis-
be reported. To report the gift, identify the source,
briefly describe the items, and show the value.
B. Items to Report
close the receipt of gifts, in-kind travel expenses,
ix. Gifts given to a spouse totally independent
and cash reimbursements by you or your spouse
of his or her relationship to you;
In the case of the figurines, report on the form un-
Identify and give the category of amount of the
X. Gift items in the nature of communications to
der
SOURCE
"Artifact Co., 153 Utah St.,
liabilities which you, your spouse or dependent
from any one source other than the U.S. Govern-
your office, such as subscriptions to news-
Omaha, NE"; and under BRIEF DESCRIPTION
child owed to any creditor, other than a relative,
ment. Generally, these are (1) gifts of in kind serv-
ices of transportation, lodging, food or entertainment
papers and periodicals;
'two porcelain figurines". Under VALUE
which exceeded $10,000 at any time during the
$120 would be shown.
reportable period, except:
aggregating $250 or more from any one source, (2)
xi. Gifts of hospitality on the donor's personal or
family premises, as defined in 5 CFR
3. REIMBURSEMENTS-Report the source and
i. a mortgage secured by real property which is
cash reimbursements aggregating $250 or more
from any one source for any kind of expense, and
the approximate value of any cash reimburse-
the personal residence (or a second residence
734.105(i);
(3) other gifts, whether tangible or intangible, ag-
ments (except those from the United States
not used for producing income) of you or your
xii. Gifts and reimbursements received during
gregating $100 or more from any one source. This
non-Federal employment periods; and
Government) aggregating $250 or more which
spouse;
reporting requirement applies to gifts and reimburse-
you or your spouse received from any one
ii. a loan secured by a personal motor vehicle,
xiii. Reimbursements you received for political
ments received by your spouse to the extent the gift
source. For example, if you were reimbursed $400
household furniture, or appliances, where the
trips which were required to be reported un-
was not given to him or her totally independent of
for travel and lodging expenses in connection with
loan does not exceed the purchase price of the
der section 304 of the Federal Election Cam-
his or her relationship to you.
a speech you made for the State Realtors Associ-
item;
paign Act of 1971 (2 U.S.C. 434).
ation, you would report this item on the form by
iii. a revolving charge account where the out-
B. Items to Report
showing
under
SOURCE
State
Realtors
As-
C. What to Show on the Form
standing liability did not exceed $10,000 as of
Report gifts received by you, your spouse or de-
soc., 45 Bridge St., Denver, CO"; under BRIEF
the close of the preceding calendar year; and
pendent child during the reporting period. A "gift"
1. TRANSPORTATION, LODGING, FOOD, ENTER-
DESCRIPTION
'travel expenses for speech
iv. any liability of your spouse or dependent child
means any payment, forbearance, advance, render-
TAINMENT-Report the identity of the source,
made in Denver"; and under VALUE "$400"
which represents the sole financial interest or
ing or deposit of money, or anything of value, un-
a brief description, and the approximate val-
would be shown. If your spouse made this speech
responsibility of the spouse or child, and about
less consideration of equal or greater value is
ue of in-kind gifts of transportation, lodging, food
and received the reimbursement totally indepen-
which you have no knowledge, and which is
received by the donor. In determining which gifts
or entertainment aggregating $250 or more from
dent of his or her relationship to you, no informa-
not related to your income, assets, or activi-
and reimbursements must be reported or aggregat-
any one source which were received by you or
tion for this item need be reported.
ties, and concerning which you neither derive
ed for purposes of meeting the threshold disclosure
your spouse and which do not fall within any of
Note: If you receive in-kind services of transporta-
nor expect to derive any financial or econom-
amounts, exclude these items:
the categories of exclusions enumerated above.
tion, lodging, food and entertainment or a
ic benefit.
To reach a $250 aggregation, you determine
i. Gifts having a value less than $35;
reimbursement of official travel expenses from
whether any one or combination of the compo-
ii. Gifts received from "relatives" (see definition
a non-profit tax-exempt institution categorized
You are required to report any liability of any com-
nents within this gift category received from one
in Introduction);
by the IRS as one falling within the terms of
pany, investment pool, or other entity, in which you,
source (transportation, lodging, food and enter-
your spouse or dependent child have an interest,
26 U.S.C. 501(c)(3), you must report the name
iii. Bequests and other forms of inheritance;
tainment) amounts to $250 or more in value. For
if (i) the entity is not described in standard reference
of the organization, a brief description of the
iv. Suitable mementos of a function honoring the
example, if you spent a weekend at a hunting
in-kind services or the reimbursement and the
materials, or (ii) the liability is not incidental to the
reporting individual;
lodge owned by AmCoal Corporation, and you
value. If known, you may also wish to note the
primary trade or business of the entity as indicated
V. Food, lodging, transportation, and entertain-
received lodging fairly valued at $150, food val-
date you received the required written ap-
by you on Schedule A. (See also section V(e) of the
ment provided by a foreign government with-
ued at $100, and entertainment valued at $125,
proval from your agency to accept such items.
General Instructions preceding those for Schedule
the aggregate value of the gift is $375. A gift of
A).
in a foreign country or by the United States
Government;
this nature-hospitality at a lodge owned by a cor-
C. What to Show on the Form
poration rather than an individual-would not
Schedule C
vi. Food and beverages consumed at banquets,
Under NAME AND ADDRESS OF CREDITOR
qualify as a "personal hospitality" exclusion. To
receptions or similar events;
the name and address of the actual creditor must
report this gift you would show, under SOURCE
I. Part I-Liabilities
vii. Gifts in-kind of food, lodging, transportation
'AmCoal Corp., 1210 North St., Chicago, IL";
be shown unless the reporting individual is only able
and entertainment aggregating less than
under BRIEF DESCRIPTION
"lodging,
food,
A. General Instructions
to identify a fiduciary and certifies in the report that
$250 in value received from any one source
he has made a good faith effort to determine who
and entertainment as a guest at hunting lodge
The Act requires you to disclose certain of your
during the preceding calendar year (for pur-
the actual creditor is and was unable to do so, or
owned by AmCoal"; and under VALUE
financial liabilities. The examples on the form show
upon his certification that such determination is
poses of the $250 aggregation in this exclu-
"$375".
how to report a mortgage on real estate the report-
sion, items with a fair market value of $35 or
otherwise impracticable. Under TYPE OF LIABILI-
2. OTHER GIFTS-Report the identity of the
ing individual held for the production of income and
TY
less need not be counted);
briefly indicate the nature of the liability. Un-
source, a brief description, and the value of
a promissory note made to an individual. Note that
der
DATE
enter date loan incurred; under IN-
viii. Gifts (other than transportation, lodging, food
gifts other than transportation, lodging, food or
you will need to disclose the date, interest rate and
TEREST RATE
note the set rate or, if a variable
or entertainment) aggregating less than $100
entertainment aggregating $100 or more in val-
term (if applicable) of each liability. Also note you
one, the formula used to vary the rate, i.e. prime
2%;
and
under
TERM
the duration of the loan.
pects to receive a lump sum payment from the law
nature. No report is required regarding any posi-
brief description of the services you provided. When
Check the category of value.
firm he has left in order to enter the Government.
tions held by your spouse or a dependent child.
a source has paid you directly, you should have a
B. What to Show on the Form
Be sure to report on Schedule A any income you
corresponding entry on Schedule A. A client who
II. Part II-Agreements or
received from acting in any of these positions.
paid your business affiliation $5,000 or more for your
Under DESCRIPTION OF TERMS
describe
Arrangements
the agreement or arrangement with appropriate
B. What to Show on the Form
services will appear only in this Part.
specificity. Under PARTIES show the name of the
Give the name, address and brief description of
B. Items to Report
A. General Instructions and
organization, or entity, and (if applicable) the name
the organization, the title or other brief functional
Report the nature of the duties performed or serv-
Items to Report
and title of the official, corporate officer, or principal
description of the position, and the dates you held
ices rendered for any person (other than the United
Provide information regarding any agreements or
person responsible for carrying out the terms of the
the position. If you currently hold the position, in the
States Government) from which compensation in ex-
agreement or arrangement. Under DATE
show
arrangements you have concerning (i) future em-
entry block under TO note "Present".
cess of $5,000 in any of the two preceding calen-
ployment; (ii) a leave of absence during your period
the date of any such arrangement. No report is re-
of Government service; (iii) continuation of payments
II. Part II-Compensation in
dar years, or the present calendar year was received
quired regarding any agreement or arrangement
by you or an entity which billed for your services
by a former employer other than the United States
entered into by a spouse or dependent child.
Excess of $5,000
(business affiliation). Exclude: (i) information to the
Government; and (iv) continuing participation in an
Paid by One Source
extent that it is considered confidential as a result
employee welfare or benefit plan maintained by a
of a privileged relationship established by law, or (ii)
former employer. This includes any arrangements
A. General Instructions
information about persons for whom services were
or negotiations with a future employer entered into
Schedule D
This Part is to be completed by nominees and new
provided by a business affiliation of which you were
by a termination filer. For purposes of public dis-
entrants only. This Act requires that you disclose
a member, partner or employee unless you were
closure only, you must disclose any negotiations for
I. Part I-Positions Held
your sources of compensation in excess of $5,000
directly involved in the provision of the services. The
future employment from the point you and a poten-
and the nature of the duties you provided. This in-
name of a client of a law firm is not generally con-
tial private sector employer have agreed to your fu-
A. Items to Report
cludes not only the source of your salary or other
sidered confidential. No report is required regard-
ture employment by that employer whether or not
Report all positions held at any time during the
fees, but the disclosure of clients for whom you per-
ing compensation paid to your spouse or a
you have settled all of the terms, such as salary, ti-
reporting period, as well as those positions you cur-
sonally provided $5,000 in services even though the
dependent child.
tle, benefits, and date employment is to begin. Your
rently hold as an officer, director, trustee, partner,
clients' payment was made to your employer, firm
agency may require internal disclosure of negotia-
proprietor, representative, employee or consultant
or other business affiliation. The example on the
C. What to Show on the Form
tions much earlier and you should seek guidance
of (i) any corporation, company, firm, partnership,
form shows the proper way to disclose the business
Under SOURCE
give the name and address
before conducting any negotiations with persons
trust, or other business enterprise; (ii) any non-profit
affiliation which paid the reporting individual's com-
of the person to whom services were provided, for
with whom you do business. A criminal statute, 18
organization; (iii) any labor organization; (iv) any
pensation, in this case a law firm, and a client of the
example, "Newark Real Estate Co. (Newark, NJ)";
U.S.C. §208, applies to actions you may take while
educational institution; or (v) other institution other
firm for whom the reporting individual personally
and under BRIEF DESCRIPTION
the title or other
negotiating future private sector employment.
than the United States Government. Exclude posi-
provided over $5,000 worth of services. This Part
brief functional description of the services rendered,
The example on the form shows the severance
tions held in any religious, social, fraternal, or polit-
does not require you to disclose the value of the
for example: "tax matters researched for above firm
agreement under which the reporting individual ex-
ical entity, and any positions solely of an honorary
compensation for these services; it does require a
while an associate with Quinn and Ouspensky".
SF 278 (Rev. 1/85)
Financial Disclosure Report
Form Approved
FPM Chapter 734
OMB No. 3206-0092
Page 1
U.S. Office of Personnel Management
Reporting Status (Check Appropriate Box)
Agency Use Only
OGE Use Only
Date of Appointment, Candidacy,
Termination Date (If Applicable)
Election or Nomination (Mo., Day, Yr.)
(Month, Day, Year)
New Entrant, Nominee,
Termination
Incumbent
or Candidate
Filer
Last Name
First Name and Middle Initial
Reporting Individual's Name
Title of Position
Department or Agency (If Applicable)
Position for Which Filing
Reporting Periods
Incumbents: Complete Schedules A, B, C, and Part I of D. The
Address (Number, Street, City, State and ZIP Code)
Telephone No. (Include Area Code)
reporting period is the preceding calendar year except for Part
Location of Present Office
II of Schedule C and Part I of Schedule D where you must also
include any positions held or agreements or arrangements made
Position(s) Held With the Federal
Title of Position(s) and Date(s) Held
from the beginning of the filing year until the date you file.
Government During the Preceding 12
Termination Filers: Complete Schedules A, B, C, and Part I
Months (If Not Same as Above)
of D. The reporting period begins at the end of the period cov-
ered by your previous filing and ends at the date of termination.
Presidential Nominees
Name of Congressional Committee Considering Nomination
Do You Intend to Create a Qualified Diversified Trust?
Nominees, New Entrants and Candidates for President and
Subject to
Senate Confirmation
Vice President: Complete Schedules A, C, and D. (Candidates
Yes
No
do not file Part II of Schedule D.)
Certification
Signature of Reporting Individual
Date (Month, Day, Year)
Schedule A-The reporting period for Income (BLOCK C) and
I CERTIFY that the statements I have
Transactions Test (BLOCK D) is the preceding calendar year
made on this form and all attached
and the current calendar year up to the date of filing. Value
schedules are true, complete and
correct to the best of my knowledge
assets in BLOCK B as of any date you choose that is within
and belief.
31 days of the date of filing.
Signature of Other Reviewer
Date (Month, Day, Year)
Other Review
Schedule C, Part I (Liabilities)-The reporting period is the
(If desired by agency)
preceding calendar year and the current calendar year up to
any date you choose that is within 31 days of the date of filing.
Agency Ethics Official's Opinion
Signature of Designated Agency Ethics Official/Reviewing Official
Date (Month, Day, Year)
Schedule C, Part II (Agreements and Arrangements)-Show
any agreements or arrangements as of the date of filing.
The information contained in this
report discloses no conflict of interest
Schedule D-The reporting period is the preceding two
under applicable laws and regulations.
calendar years and the current calendar year up to the date
Signature
Date (Month, Day, Year)
of filing.
Office of
Government Ethics
Use Only
Comments of Reviewing Officials (If additional space is required, use the reverse side of this sheet)
(Check box if comments are continued on the reverse side)
PREVIOUS EDITION USABLE
278-109
NSN 7540-01-070-8444
SF 278 (Rev. 1/85)
Form Approved
FPM Chapter 734
OMB No. 3206-0092
U.S. Office of Personnel Management
Reporting Individual's Name
Page
Schedule
Assets and Income
Number
A
All Filers: In BLOCK A report (a) the
identity of each asset held for the produc-
tion of income at the close of the reporting
All Filers: In BLOCK B report
All Filers: In BLOCK C report the type and amount of income exceeding $100 or more
period which had a fair market value ex-
the value of each asset listed in
received from the assets and other sources of income listed in BLOCK A. You must re-
Incumbents and Termination
ceeding $1000 and (b) any other asset
BLOCK A which had a fair mar-
port the actual amount of any income not of a type specifically noted below. You need
Filers only: In BLOCK D, for
or source of income which generated over
ket value exceeding $1000 at the
not report the actual amount of your spouse's earned income, only the source in BLOCK
any real property, stocks, bonds,
$100 in income during the reporting period.
close of the reporting period.
commodities futures and other
This includes but is not limited to em-
A. You may not check "qualified trust" unless you have a blind trust which has been
securities listed in BLOCK A,
ployers, stocks, bonds, tax shelters, bank
specifically approved by the Office of Government Ethics. If you, your spouse or depen-
accounts, real property, mutual funds,
did you
pensions, IRA assets, assets of certain
dent child are the beneficiary of a trust which no one of you created and has no knowl-
purchase, sell, or exchange the
trusts, commodities futures, personal busi-
edge of the assets, refer to the instructions to see if it qualifies as an "excepted trust."
item during the reporting period
nesses and partnership interests. Exclude
If "none" (or less than $101) is checked under Category of Amount of Income, no other
for a value that exceeds $1000?
your personal residence unless you rent it
entries need be made in BLOCK C for that item.
out. See instructions for rules on bank
accounts and complex holdings.
BLOCK A
BLOCK B
BLOCK C
BLOCK D
Assets & Income Sources
Valuation of Assets
Income
Transactions
Test
Category of Value (X)
Type of Income (X)
Category of Amount of Income (X)
Identify each asset and income source
Actual
If yes, complete
Other
Date
Schd. B Part for
of yours, your spouse(S) and your
Amount
None (or less
than $1001)
those assets
dependent child (DC).
$1,001-
$5,000
$5,001
$15,000
$15,001-
$50,000
$50,001
$100,000
$100,001-
$250,000
Over
$250,000
Dividends
Rent
Interest
Capital
Gains
Excepted
Trust
Qualified
(Specify
None (or less
than $101)
(Mo., Day, Yr.)
Trust
$101-
$1,000
$1,001-
$2,500
$2,501-
$5,000
$5,001-
$15,000
$15,001-
$50,000
$50,001
$100,000
$100,000
Only if
Type)
Over
"Other"
Only if
including those sold
for a loss.
Honoraria
NONE
Specified
YES
NO
S
Exam-
X Y Z Common
X
X
X
x
or
DC
ples:
Doe Jones & Smith, Hometown, USA
X
ptnrshp income
$50,000
1
2
3
4
5
6
7
8
9
10
PREVIOUS EDITION USABLE
278-209
SF 278 (Rev. 1/85)
Form Approved
FPM Chapter 734
OMB No. 3206-0092
U.S. Office of Personnel Management
Reporting Individual's Name
Page
Schedule
Number
B
Part I
Transactions
Incumbents and Termination Filers only: Report any pur-
actions that resulted in a loss. Do not report a transaction
chase, sale or exchange by you, your spouse or dependent
involving property used solely as your personal residence,
Type of Transaction (X)
Amount of Transaction (X)
child during the reporting period of any real property, stocks,
or a transaction between you, your spouse or your depen-
bonds, commodities futures, and other securities when the
dent child.
amount of the transaction exceeded $1,000. Include trans-
NONE
Purchase
Sale
Exchange
Date
(Mo., Day, Yr.)
$1,001-
$5,000
$5,001-
$15,000
$15,001-
$50,000
$50,001-
$100,000
$100,001-
$250,000
Over
$250,000
S
Exam-
Identification of Assets
or
ple:
DC
X Y Z Common
X
2/1/83
X
1
2
3
4
5
6
Part II
received from one source totaling $250 or more unless
tally independent of their relationship to you. Exclude trans-
Gifts, Reimbursements and Travel Expenses
received as personal hospitality at the donor's personal or
portation, lodging, food and reimbursements from the U.S.
family residence; (2) other gifts received from one source
Government. For (1) and (2), exclude gifts from relatives and
Incumbents and Termination Filers only:
totaling $100 or more in value; and (3) cash reimbursements
exclude gifts of $35 or less when aggregating them for the
Report the source, a brief description and the value of: (1)
of $250 or more received from one source. Exclude gifts and
total from one source. See instructions for
in-kind gifts of transportation, lodging, food or entertainment
reimbursements received by your spouse that were given to-
further exclusions.
NONE
Source (Name and Address)
Brief Description
Value
S
Exam-
Nat'l Assn. of Rock Collectors, NY, NY
Airline ticket, hotel room & meals incident to national conference 6/15/83
$500
ples:
Nat'l Assn. of Rock Collectors, NY, NY
Leather briefcase for retiring president
$125
1
2
3
4
5
6
PREVIOUS EDITION USABLE
278-108
SF 278 (Rev. 1/85)
Form Approved
FPM Chapter 734
OMB No. 3206-0092
U.S. Office of Personnel Management
Reporting Individual's Name
Page
Schedule
Number
C
Part I
Liabilities
spouse or dependent child. Check the highest amount owed
automobiles, household furniture or appliances, and liabili-
All Filers: Report liabilities over $10,000 owed to any one
during the reporting period. Exclude a mortgage on your per-
ties owed to relatives. See instructions for
creditor at any time during the reporting period by you, your
sonal residence unless it is rented out, loans secured by
revolving charge accounts.
NONE
Category of Amount or Value (X)
Term
Creditor (Name and Address)
Date
Interest
if
Type of Liability
$10,001
$15,001
$50,001
$100,001
Incurred
Rate
applic-
Over
to
to
to
to
able
$15,000
$50,000
$100,000
$250,000
$250,000
S
Exam-
First District Bank, Washington, DC
Mortgage on rental property, Rehoboth Beach, Delaware
1981
13%
25 yrs.
X
or
DC
ples:
John Jones, 123 J St., Washington, DC
Promissory note
1979
10%
on demand
X
1
2
3
4
5
6
Part II
Agreements Or Arrangements
All Filers: Report your agreements or arrangements for
or continuing participation in an employee benefit plan. See
future employment, leaves of absence, continuation of pay-
instructions regarding the reporting of negotiations for any of
ment by a former employer (including severance payments),
these arrangements or benefits.
NONE
Status and Terms of any Agreement or Arrangement
Parties
Date (Mo., Yr.)
Example:
Pursuant to partnership agreement, will receive capital account &
7/75
partnership share calculated on service performed through 11/83
Doe Jones & Smith, Home town, USA
ptnership agmnt.
PREVIOUS EDITION USABLE
278-108
SF 278 (Rev. 1/85)
Form Approved
FPM Chapter 734
OMB No. 3206-0092
U.S. Office of Personnel Management
Reporting Individual's Name
Page
Schedule
Number
D
Part I
Positions Held Outside U.S. Government
All Filers: Report any positions held during the applicable
prietor, representative, employee or consultant of any cor-
Exclude positions with religious, social, fraternal, or political
reporting period. Positions include but are not limited to
poration, firm, partnership, or other business enterprise
entities or those solely of an honorary nature.
those of an officer, director, trustee, general partner, pro-
or any non-profit organization or educational institution.
NONE
Organization (Name and Address)
Type of Organization
Position Held
From (Mo., Yr.)
To (Mo., Yr.)
Nat'l Assn. of Rock Collectors, NY, NY
Non-profit education
President
6/82
6/83
Examples:
Doe Jones & Smith, Hometown, USA
Law firm
Partner
7/75
11/83
Part II
Compensation In Excess Of $5000
Paid by One Source
Nominees and New Entrants only: Report sources of such
This includes the names of clients and customers of any cor-
services generating a fee or payment of more than $5,000.
compensation received by you or your business affiliation for
poration, firm, partnership or other business enterprise, or
You need not report the U.S. Government
services directly provided by you during the reporting period.
any nonprofit organization, when you directly provided the
as a source.
NONE
Source (Name and Address)
Brief Description of Duties
Doe Jones & Smith, Hometown, USA
Legal services
Examples:
Metro University (client of Doe Jones & Smith) Hometown, USA
Legal services in connection with university construction
PREVIOUS EDITION USABLE
278-108