**National Science Foundation**

**Arlington, VA 22230**

**Confidential Conflict-of-Interest Statement for NSF Advisory Committee
Members**

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  Name of Advisory Committee: **     **

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| In carrying out your duties as a member of an NSF advisory committee, |
| you will be called upon to give advice on NSF policy deliberations.   |
| We do not anticipate that you will ordinarily participate in any      |
| \"particular matter\". 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 interests 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 |
| of Government Ethics regulations and help the Foundation identify and |
| resolve potential (and apparent) conflicts. You must return your      |
| completed statement to the NSF official responsible for the Committee |
| before your serve on the Committee.                                   |
|                                                                       |
| 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 1: Financial Interests**                                       |
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| If **you, your spouse, or your dependent children** hold any stock,   |
| securities, or similar financial interests in any nongovernmental     |
| entity that could be affected by any NSF policy deliberation likely   |
| to come before the Committee \-- list all such holdings.              |
|                                                                       |
| \[EXAMPLE: Does your spouse hold stock in a computer company that     |
| could be affected by a change in NSF\'s standards for funding         |
| computer centers?\] 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:     |         |               |                                   |
| Pos    |         |               |                                   |
| itions |         |               |                                   |
| and    |         |               |                                   |
| Ar     |         |               |                                   |
| rangem |         |               |                                   |
| ents** |         |               |                                   |
+--------+---------+---------------+-----------------------------------+
| If any |         |               |                                   |
| entity |         |               |                                   |
| with   |         |               |                                   |
| which  |         |               |                                   |
| (i)    |         |               |                                   |
| you    |         |               |                                   |
| are    |         |               |                                   |
| now    |         |               |                                   |
| \"     |         |               |                                   |
| connec |         |               |                                   |
| ted\", |         |               |                                   |
| (ii)   |         |               |                                   |
| you    |         |               |                                   |
| are    |         |               |                                   |
| negot  |         |               |                                   |
| iating |         |               |                                   |
| to     |         |               |                                   |
| become |         |               |                                   |
| \"     |         |               |                                   |
| connec |         |               |                                   |
| ted\", |         |               |                                   |
| or     |         |               |                                   |
| (iii)  |         |               |                                   |
| you    |         |               |                                   |
| have   |         |               |                                   |
| arran  |         |               |                                   |
| gement |         |               |                                   |
| to     |         |               |                                   |
| become |         |               |                                   |
| \      |         |               |                                   |
| "conne |         |               |                                   |
| cted\" |         |               |                                   |
| in the |         |               |                                   |
| future |         |               |                                   |
| has    |         |               |                                   |
| fin    |         |               |                                   |
| ancial |         |               |                                   |
| int    |         |               |                                   |
| erests |         |               |                                   |
| that   |         |               |                                   |
| could  |         |               |                                   |
| be     |         |               |                                   |
| af     |         |               |                                   |
| fected |         |               |                                   |
| by     |         |               |                                   |
| policy |         |               |                                   |
| d      |         |               |                                   |
| eliber |         |               |                                   |
| ations |         |               |                                   |
| likely |         |               |                                   |
| to     |         |               |                                   |
| come   |         |               |                                   |
| before |         |               |                                   |
| the    |         |               |                                   |
| Com    |         |               |                                   |
| mittee |         |               |                                   |
| \--    |         |               |                                   |
| de     |         |               |                                   |
| scribe |         |               |                                   |
| all    |         |               |                                   |
| such   |         |               |                                   |
| inte   |         |               |                                   |
| rests. |         |               |                                   |
| **You  |         |               |                                   |
| are    |         |               |                                   |
| \      |         |               |                                   |
| "conne |         |               |                                   |
| cted\" |         |               |                                   |
| with   |         |               |                                   |
| any    |         |               |                                   |
| entity |         |               |                                   |
| if you |         |               |                                   |
| serve  |         |               |                                   |
| as an  |         |               |                                   |
| emp    |         |               |                                   |
| loyee, |         |               |                                   |
| of     |         |               |                                   |
| ficer, |         |               |                                   |
| dir    |         |               |                                   |
| ector, |         |               |                                   |
| tr     |         |               |                                   |
| ustee, |         |               |                                   |
| gen    |         |               |                                   |
| eral** |         |               |                                   |
| **pa   |         |               |                                   |
| rtner, |         |               |                                   |
| agent, |         |               |                                   |
| att    |         |               |                                   |
| orney, |         |               |                                   |
| consu  |         |               |                                   |
| ltant, |         |               |                                   |
| or     |         |               |                                   |
| cont   |         |               |                                   |
| ractor |         |               |                                   |
| for    |         |               |                                   |
| that   |         |               |                                   |
| ent    |         |               |                                   |
| ity.** |         |               |                                   |
|        |         |               |                                   |
| \[EXA  |         |               |                                   |
| MPLES: |         |               |                                   |
| (1) Is |         |               |                                   |
| your   |         |               |                                   |
| em     |         |               |                                   |
| ployer |         |               |                                   |
| one of |         |               |                                   |
| NSF\'s |         |               |                                   |
| c      |         |               |                                   |
| urrent |         |               |                                   |
| s      |         |               |                                   |
| cience |         |               |                                   |
| and    |         |               |                                   |
| tech   |         |               |                                   |
| nology |         |               |                                   |
| center |         |               |                                   |
| gra    |         |               |                                   |
| ntees, |         |               |                                   |
| and    |         |               |                                   |
| the    |         |               |                                   |
| Com    |         |               |                                   |
| mittee |         |               |                                   |
| could  |         |               |                                   |
| rec    |         |               |                                   |
| ommend |         |               |                                   |
| f      |         |               |                                   |
| unding |         |               |                                   |
| levels |         |               |                                   |
| for    |         |               |                                   |
| the    |         |               |                                   |
| s      |         |               |                                   |
| cience |         |               |                                   |
| and    |         |               |                                   |
| tech   |         |               |                                   |
| nology |         |               |                                   |
| center |         |               |                                   |
|        |         |               |                                   |
| pr     |         |               |                                   |
| ogram? |         |               |                                   |
| If so, |         |               |                                   |
| name   |         |               |                                   |
| the    |         |               |                                   |
| em     |         |               |                                   |
| ployer |         |               |                                   |
| and    |         |               |                                   |
| grant  |         |               |                                   |
| inv    |         |               |                                   |
| olved. |         |               |                                   |
|        |         |               |                                   |
| \(2\)  |         |               |                                   |
| Are    |         |               |                                   |
| you an |         |               |                                   |
| o      |         |               |                                   |
| fficer |         |               |                                   |
| in a   |         |               |                                   |
| profes |         |               |                                   |
| sional |         |               |                                   |
| assoc  |         |               |                                   |
| iation |         |               |                                   |
| that   |         |               |                                   |
| has    |         |               |                                   |
| di     |         |               |                                   |
| rectly |         |               |                                   |
| nego   |         |               |                                   |
| tiated |         |               |                                   |
| with   |         |               |                                   |
| the    |         |               |                                   |
| NSF on |         |               |                                   |
| an     |         |               |                                   |
| issue  |         |               |                                   |
| the    |         |               |                                   |
| Com    |         |               |                                   |
| mittee |         |               |                                   |
| is     |         |               |                                   |
| likely |         |               |                                   |
| to     |         |               |                                   |
| di     |         |               |                                   |
| scuss? |         |               |                                   |
|        |         |               |                                   |
| If so, |         |               |                                   |
| name   |         |               |                                   |
| the    |         |               |                                   |
| assoc  |         |               |                                   |
| iation |         |               |                                   |
| and    |         |               |                                   |
| the    |         |               |                                   |
| issue  |         |               |                                   |
| invol  |         |               |                                   |
| ved.\] |         |               |                                   |
| NONE   |         |               |                                   |
+--------+---------+---------------+-----------------------------------+
| (*Id   | *(Type  | *(Interest or |                                   |
| entify | of      | issue         |                                   |
| sp     | po      | involved)*    |                                   |
| ecific | sition, |               |                                   |
| o      | arra    |               |                                   |
| rganiz | ngement |               |                                   |
| ation, | or      |               |                                   |
| or     | other   |               |                                   |
| en     | conne   |               |                                   |
| tity)* | ction)* |               |                                   |
+--------+---------+---------------+-----------------------------------+
| 1      |         |               |                                   |
| .      |         |               |                                   |
+--------+---------+---------------+-----------------------------------+
| 2\.    |         |               |                                   |
|        |         |               |                                   |
+--------+---------+---------------+-----------------------------------+
| 3\.    |         |               |                                   |
|        |         |               |                                   |
+--------+---------+---------------+-----------------------------------+
| 4\.    |         |               |                                   |
|        |         |               |                                   |
+--------+---------+---------------+-----------------------------------+

+-----------------------------------------------------------------------+
| **Part 3: Other Interests or Relationships**                          |
+-----------------------------------------------------------------------+
| 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?                            |
|                                                                       |
| \[EXAMPLE: Does your best friend stand to benefit by a change in      |
| NSF\'s administration of the program your committee is advising? If   |
| so, briefly describe. \] 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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| 8\.                                                                   |
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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 the Foundation, 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**                                 |
+-----------------------------------------------------------------------+
| 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 NSF        |
| 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 NSF OFFICIAL**                         |
+-----------------------------------------------------------------------+
| Based on my review of this form, I certify that:                      |
|                                                                       |
| No conflicts identified.                                              |
|                                                                       |
| Other actions taken (explain.).                                       |
|                                                                       |
| \-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\                                 |
| -\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\- |
| \-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\ |
| -\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\- |
| \-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\ |
| -\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\- |
| \-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-- |
|                                                                       |
| Signature Date                                                        |
+-----------------------------------------------------------------------+

+-----------------------------------+-----------------------------------+
| **Privacy Act Statement**         | **Public Burden Information**     |
|                                   |                                   |
| required by section (e)(3) of the | This collection is estimated to   |
| Privacy Act                       | take an average of a half hour    |
|                                   | per response, including time for  |
| Title I of the Ethics in          | reviewing the instructions,       |
| Government Act of 1978 (5 U.S.C.  | gathering the data needed, and    |
| App.), Executive Order 12674, and | completing the form. Send         |
| 5 CFR Part 2634, Subpart I, of    | comments regarding the burden     |
| the Office of Government Ethics   | estimate or any other aspect of   |
| regulations require the reporting | this collection of information,   |
| of this information before you    | including suggestions for         |
| may serve on a Federal advisory   | reducing this burden, to: Reports |
| committee. The primary use of the | Clearance Officer, NSF, 4201      |
| information on this form is for   | Wilson Blvd., Arlington, VA       |
| review by officials of this       | 22230; and to the Office of       |
| agency, to determine compliance   | Management and Budget, Paperwork  |
| with applicable Federal conflict  | Reduction Project (3209-0006),    |
| of interests laws and             | Washington, DC 20503. Do not send |
| regulations. This confidential    | your completed statement to these |
| report will not be disclosed to   | addressees. Return your completed |
|                                   | statement to the NSF Committee    |
| any requesting person unless      | official who sent it to you.      |
| 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.                      |                                   |
+-----------------------------------+-----------------------------------+

NSF FORM 1230A (3/08)

1 - File in Advisory Committee File

2 - Send a copy to the OGC Conflicts Official

NATIONAL SCIENCE FOUNDATION

OFFICE OF THE GENERAL COUNSEL

**Advisory Committee Ethics Law Summary**

As a \"special\" Government employee, most Federal ethics laws and
regulations apply to you. They apply alike to individuals carrying out a
wide variety of Government tasks. Thus some rules will inevitably be
less relevant to your duties than others. Even so, your careful
adherence to the rules should foster public confidence that NSF's
decision-making processes are not tainted by improper influences. That
is why Executive Order 12674 further cautions all employees to
\"endeavor to avoid any action creating the appearance that they are
violating the law or the ethical standards\".

**I. [DISQUALIFICATIONS]{.underline}**

A. Absent a specific written dispensation, a criminal statute bars your
participation in your Government capacity in [any]{.underline}
particular matter, if you have a financial interest in the outcome;
[or]{.underline} if any of the following individuals or entities have
financial interests in the outcome:

-   Your spouse or minor child

-   A business partner

-   An organization with which you are employed or affiliated as an
    officer, director, trustee, or partner

-   An organization with which you have an arrangement for future
    employment

-   An organization with which you are negotiating for employment.

B. Regulations also restrict your participation in [specific party
matters]{.underline} involving:

-   Relatives or members of your household

-   Current and former thesis advisors or thesis students

-   Individuals with whom you have collaborated within the past 4 years

-   Individuals or entities with whom you have (or seek) business or
    financial relationships

-   Entities your spouse, parents, or dependent children work for (or
    seek to work for) as employees, officers, directors, trustees,
    consultants, etc.

-   Entities you have served as an employee, officer, director, trustee,
    consultant, etc. within the past 12 months

-   Organizations in which you are an active participant \-- *e.g*.,
    committee chair or spokesperson.

C. Questions about potential dispensations should be addressed to the
General Counsel\'s Office.

**II. [MISUSE OF POSITION]{.underline}**

A. Do not use or disclose non-public Government information.

B. Do not use your public office for private gain (whether your own or
another\'s).

**III. [REPRESENTATION]{.underline}**

A. A criminal statute provides that:

-   You must not represent someone else before the Government on any
    [specific party matter]{.underline} in which you have participated
    as a Government employee.

-   If you have been employed by NSF for more than sixty days in a
    365-day period, you must not represent anyone in dealings with NSF
    officials on any [specific party matter]{.underline}.

This law also bars you from accepting fees from such representation done
by others.

B. Another law bars you from serving as an agent of a foreign principal,
as defined in the Foreign Agents Registration Act.

**IV. [RECEIPT OF GIFTS]{.underline}**

A. Basic Rule: Do not solicit or accept gifts and favors from any
\"prohibited source\" \-- any individual or organization who:

-   Seeks official action from NSF;

-   Does, or seeks to do, business with NSF;

-   Conducts activities regulated by NSF;

-   Has interests that may be substantially affected by the performance
    of your official duties; or

-   Is an organization the majority of whose members are described
    above.

B. Commonly invoked Exceptions include permission to accept:

-   Benefits resulting from your non-NSF business or employment
    activities (or those of your spouse), when it is clear that the
    benefits have not been offered or enhanced because of your
    Government status

-   Gifts clearly motivated by family relationship or personal
    friendship

-   Items worth \$20 or less per occasion \-- up to \$50 a year from any
    one source.

Exceptions should not be abused.

Please contact your Divisional Conflicts Official or the Office of
General Counsel at 703-292-8060 if you have any questions.