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-8- ^[[SUGGESTED CHANGE]] [[preprinted]] SI-1085 Rev. 8-13-79 [[underlined]] CONFIDENTIAL STATEMENT OF EMPLOYMENT AND FINANCIAL INTERESTS [[/underlined]] [[underlined]] Instructions: [[/underlined]] This form is designed to include the [[strikethrough]] minimum [[/strikethrough]] ^pertinent information relevant to possible conflicts of interest, and the requirement to report an item does not indicate it is improper. Attach additional sheets, if needed, identifying each sheet with your name, position, and the section of this form being continued. When values are required to check the applicable category, or where dollar amounts are required provide [[white dot blocking word]] based on your own good faith estimate, an appraisal, or other objective criteria. Each section and subsection must be completed or 'none' checked where applicable. [[underlined]] Confidentiality: [[/underlined]] This report is confidential and will be maintained in a locked file safe in the office of the Smithsonian Ethics Counselor, and access will be provided only to officials responsible for reviewing these forms and those officials with specific audit authority over these financial disclosure forms. [[underlined]] Reporting Period: [[/underlined]] The period covered by this report is the preceding calendar year, and reports are due on the date specified in the attached memorandum. This report also must be completed as part of the exit clearance procedure by persons leaving the Smithsonian, and their financial reports must include information for the preceding calendar year (unless already reported) plus the current calendar year up to the date of termination. The list of "Positions Held" (Section VII) ^[[stamped underneath]] and Section VIII [[/stamped]] also requires reporting for the current calendar year. [[underlined]] Parties whose interests must be reported: [[/underlined]] In addition to information about yourself, each employee's report must include information, as called for in each section, concerning the income, and property interests of a spouse or dependent child, as well as certain gifts and reimbursements they may have received. "Dependent child" includes any child or stepchild under age 21 who lives in your household, or any child or stepchild you support in whole or in part, such that you claim them as a dependent on your income tax returns. Do [[underlined]] not [[/underlined]] report the interests of a spouse with whom you do not reside, unless he/she is a dependent. The Source(s) of earned income in excess of $1,000 received by a spouse must be reported separately in Secion II and designed (S). You need [[underlined]] not [[/underlined]] separately identify (although you must report) other income, assets, or interests of or gifts and reimbursements to a spouse or dependent child, although you [[underlined]] may [[/underlined]] do so by designating such items with an (S) or (C). [[2 rows of 2 boxes each]] A. Name (Last Name, First, Middle Initial) | B. Position(s) held in the Smithsonian during reporting period C. Bureau, office, department, or unit | D. Approximate date of appointment to present position [[end of boxes]] I. INVESTMENT INCOME (employee, spouse, and dependent child) [[table with 5 columns]] [[above 2nd column]] SOURCE (When identifying securities give name of issuing company; if not listed on stock exchanges, give address and nature of business. Provide basic information for other sources.) [[atop columns 3 through 5]] Check ([[checkmark]]) Category of Amount or Value [[above column 3]] $100 to $1,000 [[above column 4]] $1,000 to $10,000 [[above column 5]] Over $10,000 [[in column 1, box 1]] (a) DIVIDENDS (e.g., from stocks, bonds, mutual funds, etc.) [[in column 2, box 1]] [[box]] 'None' [[in column 1, box 2]] (b) RENTS (and other income from real property) [[in column 2, box 2]] [[box]] 'None' [[in column 1, box 3]] (c) INTEREST (e.g., from corporate bonds, bills & notes, loans, pension funds, etc.) [[in column 2, box 3]] [[box]] 'None' [[in column 1, box 4]] (d) CAPITAL GAINS (e.g., from real and personal property & securities transactions etc.) [[in column 2, box 4]] [[box]] 'None' [[in column 1, box 5]] (e) TRUST INCOME (for you, spouse, & child) [[in column 2, box 5]] [[box]] 'None' [[in column 1, box 6]] (f) OTHER INVEST- MENT INCOME (i.e., not covered above from business interests, distributive share of partnership, annuities & pensions, etc.) [[in column 2, box 6]] [[box]] 'None' [[in column 1, box 7]] Continuation space for Section I INVEST- MENT INCOME (State subsection(s) being continued) [[left of the table]] List the source and amount of income which exceeded $100 from any single source during the reporting period. Exclude: Any amounts and values aggregating uder $100 from any one source; income from sale or exchange of property not held for investment, e.g., used for furnishing of your residence, for person- al transportation, or for other personal purposes; gains from sale or exchange of your residence, inter- est on bank or savings and loan accounts, credit union balances, or certificates of de- posit; interest from municipal, state, or federal bonds; or from loans to rela- tives excluded under Section IV. [[at bottom of document]] OSS Supply Item #754-71 1