**Department of Energy**

1000 Independence Avenue, S.W., Washington, DC 20585

Confidential Conflict-of-Interest Statement for DOE Advisory Committee
Members

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  Name of Advisory Committee:

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Member's name: Member's phone number:

Member's address:

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| In carrying out your duties as a member of a DOE advisory committee,  |
| you will be called upon to give advice on DOE policy deliberations.   |
| We do not anticipate that you will ordinarily participate in any      |
| "particular matter involving specific parties". However, sometimes    |
| policy deliberations focus on the interests of specific persons or    |
| organizations or on a discrete class of specific persons or entities. |
| In such cases, your personal financial interest or your affiliations  |
| or relationships with other affected persons or entities may raise    |
| conflict-of-interest questions. By providing the information          |
| requested on this form, you will satisfy a requirement of U.S. Office |
| Government Ethics regulations and help DOE personnel identify and     |
| resolve potential and apparent conflicts. You must return your        |
| completed statement to the Committee Designated Federal Officer       |
| responsible for the Committee prior to participating in Committee     |
| activity.                                                             |
|                                                                       |
| For each of the three parts below list all interests, positions,      |
| arrangements, or relationships you think might reasonably be          |
| responsive. If you have none, check the "NONE" box.                   |
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| Part I: Financial Interests                                           |
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| If **you, your spouse, or your dependent children** receive any       |
| income (compensation, honoraria, royalties, etc.), hold any stock,    |
| securities, or similar financial interests in any nongovernmental     |
| entity that could be affected by DOE policy deliberations likely to   |
| come before the Committee -- list all such interests.                 |
|                                                                       |
| EXAMPLE: Does your spouse hold stock in a company that could be       |
| affected by a change in DOE's research priorities?                    |
|                                                                       |
| NONE \[ \]                                                            |
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| (Identify specific business, stock, bond, etc.)                       |
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| 1\.                                                                   |
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| 2\.                                                                   |
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| 3\.                                                                   |
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| 4\.                                                                   |
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| 5\.                                                                   |
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| Part 2: Positions and |                       |                      |
| Arrangements          |                       |                      |
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| If any entity with    |                       |                      |
| which (i) you are now |                       |                      |
| "connected", (ii) you |                       |                      |
| are negotiating to    |                       |                      |
| become "connected",   |                       |                      |
| or (iii) you have     |                       |                      |
| arrangement to become |                       |                      |
| "connected" in the    |                       |                      |
| future has financial  |                       |                      |
| interests that could  |                       |                      |
| be affected by policy |                       |                      |
| deliberations likely  |                       |                      |
| to come before the    |                       |                      |
| Committee -- describe |                       |                      |
| all such interests.   |                       |                      |
| **You are "connected" |                       |                      |
| with any entity if    |                       |                      |
| you serve as an       |                       |                      |
| employee, officer,    |                       |                      |
| director, trustee,    |                       |                      |
| general partner,      |                       |                      |
| agent attorney,       |                       |                      |
| consultant, or        |                       |                      |
| contractor for that   |                       |                      |
| entity.**             |                       |                      |
|                       |                       |                      |
| EXAMPLES: (1) Are you |                       |                      |
| connected with a      |                       |                      |
| professional          |                       |                      |
| association,          |                       |                      |
| university, national  |                       |                      |
| laboratory, or        |                       |                      |
| corporation, that has |                       |                      |
| a direct grant,       |                       |                      |
| contract, cooperative |                       |                      |
|                       |                       |                      |
| agreement or other    |                       |                      |
| financial             |                       |                      |
| relationship with DOE |                       |                      |
| or parties that may   |                       |                      |
| be affected by        |                       |                      |
| recommendations of    |                       |                      |
| the Committee (i.e.   |                       |                      |
| recommendation        |                       |                      |
|                       |                       |                      |
| for current or future |                       |                      |
| funding, closure of   |                       |                      |
| facilities, or        |                       |                      |
| selection of one type |                       |                      |
| of research over      |                       |                      |
| another, etc.)? If    |                       |                      |
| so, name the other    |                       |                      |
| entity and grant,     |                       |                      |
|                       |                       |                      |
| contract, cooperative |                       |                      |
| agreement or other    |                       |                      |
| financial             |                       |                      |
| relationship          |                       |                      |
| involved.             |                       |                      |
|                       |                       |                      |
| \(2\) Are you an      |                       |                      |
| officer in a          |                       |                      |
| professional          |                       |                      |
| association that has  |                       |                      |
| directly negotiated   |                       |                      |
| with the DOE on an    |                       |                      |
| issue the Committee   |                       |                      |
| is likely to discuss? |                       |                      |
|                       |                       |                      |
| If so, name the       |                       |                      |
| association and the   |                       |                      |
| issue involved. NONE  |                       |                      |
| \[ \]                 |                       |                      |
+-----------------------+-----------------------+----------------------+
| (Identify specific    | (Type of position,    | (Interest or issue   |
| organization, or      | arrangement or other  | involved)            |
| entity)               | connection            |                      |
+-----------------------+-----------------------+----------------------+
| 1\.                   |                       |                      |
+-----------------------+-----------------------+----------------------+
| 2\.                   |                       |                      |
+-----------------------+-----------------------+----------------------+
| 3                     |                       |                      |
+-----------------------+-----------------------+----------------------+
| 4                     |                       |                      |
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| Part 3: Other Interests or Relationships                              |
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| Are you aware of any other interests, affiliations, or relationships  |
| you believe would impair your impartiality in any policy              |
| deliberations likely to come before the Committee, or that would      |
| cause a reasonable person with knowledge of the relevant facts to     |
| question your impartiality in such matter?                            |
|                                                                       |
| EXAMPLE: Does your best friend stand to benefit by a change in DOE's  |
| administration of the program your committee is advising? If so,      |
| briefly describe. NONE \[ \]                                          |
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| 1\.                                                                   |
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| 2\.                                                                   |
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| 3\.                                                                   |
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| 4\.                                                                   |
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| 5\.                                                                   |
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| 6\.                                                                   |
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| 7                                                                     |
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  If your designation as an advisory committee member gives you access to
  information not generally available to the public, you must not use
  that information for your personal benefit or make it available for the
  personal benefit of any other individual or organization. This is to be
  distinguished from the entirely appropriate general benefit of learning
  more about DOE programs, learning from other advisory committee
  members, or becoming better acquainted with the state of a given
  discipline.

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| COMMITTEE MEMBER'S CERTIFICATION                                      |
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| I certify that my answers to the above questions are true to the best |
| of my knowledge. I also understand that I must contact the DOE        |
| Designated Federal Official responsible for the Committee if a        |
| conflict exists or arises during my term of service. I also will not  |
| divulge any confidential information I may become aware of during my  |
| term.                                                                 |
|                                                                       |
| Member's Name (Please Print) Signature Date                           |
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| CERTIFICATION BY RESPONSIBLE DOE OFFICIAL                             |
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| Based on my review of this form, I certify that:                      |
|                                                                       |
| \[ \] No conflicts identified.                                        |
|                                                                       |
| \[ \] Waiver will be granted by separate document pursuant to 18 USC  |
| § 208 (b)(3) because the need for the individual's services outweighs |
| the potential for a                                                   |
|                                                                       |
| conflict of interest created by the financial interest involved.      |
|                                                                       |
| \[ \] Other actions taken (explain).                                  |
|                                                                       |
| Signature Date                                                        |
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+-----------------------------------+-----------------------------------+
| **Privacy Act Statement**         |                                   |
|                                   |                                   |
| required by section (e)(3) of the |                                   |
| Privacy Act                       |                                   |
|                                   |                                   |
| Title I of the Ethics in          |                                   |
| Government Act of 1978 (5 U.S.C.  |                                   |
| App.), Executive Order 12674, and |                                   |
| 5 CFR Part 2634, Subpart I, of    |                                   |
| the Office of Government Ethics   |                                   |
| regulations require the reporting |                                   |
| of this information before you    |                                   |
| may serve on a Federal advisory   |                                   |
| committee. The primary use of the |                                   |
| information on this form is for   |                                   |
| review by officials of any        |                                   |
| agency, to determine compliance   |                                   |
| with applicable Federal conflict  |                                   |
| of interests laws and             |                                   |
| regulations. This confidential    |                                   |
| report will not be disclosed to   |                                   |
| any requesting person unless      |                                   |
| authorized by law. Failure to     |                                   |
| file this form will preclude your |                                   |
| service on the advisory           |                                   |
| committee. Knowing and willful    |                                   |
| falsification of information      |                                   |
| required to be reported could     |                                   |
| subject you to criminal           |                                   |
| prosecution.                      |                                   |
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