HOW TO COMPLETE A CONFIDENTIAL FINANCIAL DISCLOSURE REPORT

1. HOW TO COMPLETE A CONFIDENTIAL FINANCIAL DISCLOSURE REPORT

2. Fill in: 1) name, 2) title, 3) grade, and 4) reporting status 1. 2. 3. 4.

3. EXAMPLE ContractingSpecialist Dole, Thomas T. GS-14 x

4. What is my Reporting Status ? x 4. NEW ENTRANT: Check this box if you are a first time filer or if you are a Special Government Employee (SGE). You are required to file within 30 days of entering your covered position. An SGE is an officer or employee who performs temporary duties, compensated or not, for a time period not to exceed 130 days during any period of 365 consecutive days. FSA STATE COMMITTEE MEMBERS ARE SGEs

5. 4) Continue - What is my Reporting Status? 4. X ANNUAL: Check this box if filing as an incumbent. An incumbent is an officer or employee who performs the duties of a covered position for a period in excess of 60 days during a 12 month period ending 9/30.

6. Fill in: 5) Agency, 6) Branch & Address, 7) Work Phone, and 8) Date of Appt. 5. 6. 7. 8** **Date required if New Entrant

7. EXAMPLE Dole, Thomas T. Contracting Specialist GS-14 x Farm Service Agency DACO/PDD 202 720-0000 1/13/2005

8. 8) Are you a Special Government Employee (SGE)? 8. x * If you are an SGE, please check this box and provide your home address in the next box*.

9. EXAMPLE Polk, Carol S. State Committee Member GS 14 x Farm Service Agency Alabama State Office - P.O Box 1 555 222-0000 1/1/2005 x 222 Spring Road 12, Sunny. Alabama 36774

10. PART I: ASSETS & INCOME

11. Assets and Income • You must report in Part I any asset worth: • more than $1,000 at the end of the reporting period or • producing income over $200. • Put a check next to those assets that have a value of $15,001. 10.

12. Reportable Assets • Bonds • Investment Real Estate • Pensions • IRA/401K Holdings • Commodity Futures • Partnership Interests • Collectibles held for investment • Stocks • Tax Shelters • Mutual Funds • Annuities • Trust Holdings • Trades & Business • Investment Life Insurance

13. Reportable Income • Dividends • Rents & Royalties • Interest & Capital Gains • Fees • Salaries • Commissions • Retirement Benefits • Honoraria

14. Example: Assets and Income 10. Dividends x Vanguard 500 Index fund (ASSET) (INCOME)

15. Assets and Income Cont. Only Include this page if additional space is needed to list assets and income.

16. Farm Assets and Income • The filer must describe the asset clearly and with enough detail that the reviewer can understand what the asset is. The listing must include: • The type of interest in the farm, such as limited partner, general partner, sole owner, or corporate shareholder. • The name under which the farm does business • The business of the farm, such as corn or livestock. • The location of the farm (city and state).

17. Example: Farm Assets and Income 10. Livestock x Sole Owner, Jim Cattle Ranch, Omaha, NE

18. Spousal Employment 10. • DO: list the NAME of the employer or name of business (if spouse is self-employed); • identify the nature of business; • identify your spouse’s position or title; • list the location (city/state). • DO NOT report the AMOUNT of income.

19. Example: Spousal Employment 10. Salary (S) Bowes Law Firm - Attorney Wash. DC

20. Mutual Funds, UIT, and Similar Investments. List the full name of the investment (e.g., Fidelity Aggressive Growth Fund).

21. Example: Mutual Fund 10. Fidelity Aggressive Growth Fund Dividends (D) Janus Adviser Balanced A Capital Gains (CG) Walden Social Equity D & CG

22. IRAs, 401ks, 403s, Keoughs, etc Report any UNDERLYING assets that you would be required to report if held individually rather than as part of the plan. For example, let’s assume that your Merrill Lynch 401k has four underlying assets: AIM International Fund, Fidelity Magellan Fund and Exxon-Mobil stock, which individually are worth more than $1,000; and IBM stock which is worth less than $1,000 and generated income less than $200. How should these assets be reported? Let’s see…

23. Example: Individual Retirement Account 10. MerrillLynch 401K containing: AIM International Fund Fidelity Magellan Fund Exxon Mobil D & CG You would not report the IBM stock.

24. Inclusion of City and State Include location (city and state) for the following listings in Part I. a. Any private businesses listed;b. Non-public companies in which you list stock; andc. Rental and commercial property listed.

25. Example: If No Longer Held 10. D Fidelity Aggressive Growth Fund x Check this block for any asset which is no longer held at the end of the reporting period, but which must still be listed because it generated over $200 income during the reporting period.

26. Example: Reporting Honoraria 10. (S) Time Magazine Honoraria 03/05 Honoraria – means payment of money or anything of value to you or your spouse for an appearance, speech or article, excluding necessary travel expenses. Also included are payments to charities in lieu of honoraria. Report the source and date service was provided (month and year)..

27. Excluded Assets DO NOT LIST THESE ASSETS ON YOUR REPORT • Personal residence, unless rented out • Fed. Salary or Federal Retirement Benefits • Social Security • $ owed to filer, spouse, or dependent child by spouse, parent, sibling or child • Bank Accounts • Money Market Mutual Funds and Accounts • Government Obligations • Government Securities • Underlying holdings in a Blind Trust

28. PART II: LIABILITIES

29. Liabilities 11. Credit Card Debt Student loans Liabilities +$10,000 owed to any creditor at any time during the reporting period. Includes liabilities of spouse and dependent children.

30. Reportable Liabilities • Mortgages on rental properties; • Business Loans; • Student Loans; and • +$10,000 revolving charge accounts.

31. Example: Reporting Mortgage 11. Mortgage on Rental Property Oxon Hill, MD First Va Bank, Alex., VA

32. Excluded Liabilities • Cars, household furniture, or appliances; • Mortgages on personal residences; • Loans from relatives; & • Revolving charge accounts not exceeding $10,000 at end of reporting period.

33. PART III: OUTSIDE EMPLOYMENT

34. Outside Positions 12. Remember to provide sufficient information so that the reviewer can comprehend the nature of the outside position & submit a copy of your prior approval for outside employment with your OGE 450 form. You may obtain the prior approval form, at the following web address: http://www.usda-ethics.net/forms/nonfederalemployment.pdf

35. Reportable Outside Positions Compensated & Uncompensated Positions: • Employee/Officer/Director/Trustee; • General Partner/Proprietor; • Representative/Executor; and • Consultant for a business/non-profit or labor organization or educational institution.

36. Example: Reporting Outside Position 12. Financial Tech. Inc., , Alex. VA ConsultantFirm Employee Jim Cattle Ranch, Omha, NE Farming Business Proprietor Charles A. Smith, Corp. Realtor Employee X

37. Excluded Positions DO NOT LIST THESE POSITIONS ON YOUR REPORT • Positions held in religious, social, fraternal, or political organization; • Honorary positions; and • Positions with the Federal Government. • Excludes positions held by spouse or dependent children.

38. PART IV: AGREEMENTS OR ARRANGEMENTS

39. Agreements and Arrangements Report your agreements or arrangements for current or future employment; leave of absence from non-federal employment, etc. Note: If you have a retirement plan, savings plan, stock purchase option, severance payment, or other plan with a former employer, this needs to be reflected on both Parts I and IV 13.

40. Reportable Agreements & Arrangements • Current or future employment; • Leaves of absence from non-Federal employment; • Continuation of salary by a former non-Federal employer; and • Continuing participation in Non-Federal pension or benefit plan.

41. Example: Reporting Agreements & Arrangements 13. Charles A. Smith Corp., Alex., VA Will receive retained Pensions benefits 2/10

42. Excluded Agreements & Arrangements Those of a spouse or dependent child. However, don’t forget that spouse’s non- Federal pension or work arrangement should be listed on Part I.

43. Gifts and Travel Reimbursements Report gifts & travel for you, your spouse, and dependent children received totaling more than $305. Do not report gifts or travel you received on behalf of the agency to carry out your official duties, or gifts from relatives or friends. 14.

44. Reportable Gifts &Travel Reimbursements • Doesn’t apply to new entrants & SGEs. • Reportable only for annual filers. • Gifts & travel from one source totaling $305 or more (other than U. S. Government). • Includes gifts to spouseand dependent children.

45. Excluded Gifts &Travel Reimbursements • Gifts valued under $305; • Anything received by spouse or dependent child totally independent of their relationship to filer; • From relative or from U.S. government; and • Anything accepted by the Agency (e.g. Travel Acceptance under 31 U.S.C. 1353).

46. Example: Reporting Gifts & Travel Reimbursements 14. Charles A. Smith Corp. Alex, VA Briefcase as a departing gift 12/04 Bowes Law Firm, Wash. DC. Gold Pen set for Employee of the Month 10/04

47. 15) Numbering the Pages *** *** 1 1 2 *** 3 *** I know, it seems simple, but incomplete forms require follow-up phone calls and more work for everybody.

48. IMPORTANT! Checking the None Box

49. x

50. x x x x