FORM OSM 23 (8/89) UNITED STATES DEPARTMENT OF THE INTERIOR Approved by
OMB

Office of Surface Mining Reclamation and Enforcement CN 1029-0067

State Employee Statement of Employment and Financial Interest Expires:
9/30/11

  ----------------------------------- ----------------- -----------------
  1\. Name (Last, First, Initial)     2\. Title of      
                                      Position          

  3\. Date of Appointment (in present 4\.               
  position)                           Organizational    
                                      Unit              

  5\. Duty Station (Office location)  6\. Telephone No. 7\. Calendar Year
                                                        (previous)
  ----------------------------------- ----------------- -----------------

**General Instructions.** Report all interests held during the previous
calendar year (indicate which ones are no longer held), use attachments
as necessary. In the event any of the required information is not known
to you, but is known to another person (e.g., trustee, accountant,
relative), you should request that other person to submit the
information on your behalf. Give the name and address of the other
person, and include the date you requested the information to be
supplied. Briefly explain the situation and the information requested.
*Codes =* (E) for Employee, (J) for Joint ownership with spouse, minor
child or other relatives, (S) for Spouse, (C) for minor child or (R) for
other Relatives who are full-time residents in your immediate household.

**Part I. Employment and Securities.** List the names of business
entities, non-profit organizations, educational and other institutions
in which you, your spouse, minor child or other relatives who are
full-time residents of your immediate household have: (1) an interest as
an employee, officer, owner, director, trustee, partner or consultant;
(2) a continuing financial interest through a pension or retirement
plan, individual retirement account, shared income, or other arrangement
as a result of any current or prior employment; (3) any financial
interest through the ownership of stock, bonds, securities or other
arrangement including trusts. ***You may exclude:*** (1) positions with
charitable, religious, fraternal, political organizations or any similar
organization and those solely of an honorary nature; (2) holdings in
widely held diversified mutual funds, investment clubs or regulated
investment companies not specializing in underground and surface coal
mining operations; (3) employment, pension or retirement plans with the
U.S. or State Governments; (4) retirement plans with a guaranteed
income. A guaranteed income is one which is unlikely to be changed as a
result of actions taken by the State regulatory authority.

NONE

+-----+--------------------------+----------------+-------------------+
| C   | Name and Address of      | Description of | Nature of         |
| ode | Organization             | Interest       | Employment and    |
| J,  |                          |                | Financial         |
| S,  |                          | (e.g.,         | Interest (e.g.,   |
| C   |                          | employment,    | salary,           |
| or  |                          | stock)         | dividends)        |
| R   |                          |                |                   |
+-----+--------------------------+----------------+-------------------+
|     |                          |                |                   |
+-----+--------------------------+----------------+-------------------+
|     |                          |                |                   |
+-----+--------------------------+----------------+-------------------+
|     |                          |                |                   |
+-----+--------------------------+----------------+-------------------+
|     |                          |                |                   |
+-----+--------------------------+----------------+-------------------+

**Part II. REAL PROPERTY.** List property in which you, your spouse,
minor child or other relatives who are full-time residents of your
immediate household have an interest. *Exclude* your personal residence.
Personal residents means any real property used exclusively as a private
dwelling.

NONE

+-----+--------------------------+----------------+-------------------+
| C   | Nature of Interests      | Description of | Location of       |
| ode | (e.g., ownership,        | Interest       | Interest          |
| J,  |                          |                |                   |
| S,  | lease, royalty, mineral  | (e.g.,         | (county and       |
| C   | rights)                  | employment,    | state)            |
| or  |                          | stock)         |                   |
| R   |                          |                |                   |
+-----+--------------------------+----------------+-------------------+
|     |                          |                |                   |
+-----+--------------------------+----------------+-------------------+
|     |                          |                |                   |
+-----+--------------------------+----------------+-------------------+

**Part III. CREDITORS.** List debts owed to business entities and
non-profit organizations to whom you, your spouse, minor child or other
relatives who are full-time residents of your immediate household are
indebted. *Exclude* debts owed to financial institutions (e.g., banks,
credit unions), credit cards, and those for ordinary household and
living expenses.

NONE

+-----+--------------------------+----------------+-------------------+
| C   | Nature of Interests      | Description of | Location of       |
| ode | (e.g., ownership,        | Interest       | Interest          |
| J,  |                          |                |                   |
| S,  | lease, royalty, mineral  | (e.g.,         | (county and       |
| C   | rights)                  | employment,    | state)            |
| or  |                          | stock)         |                   |
| R   |                          |                |                   |
+-----+--------------------------+----------------+-------------------+
|     |                          |                |                   |
+-----+--------------------------+----------------+-------------------+

**Part IV. EMPLOYEE CERTIFICATION.** To the best of my knowledge, none
of the employment and financial interests listed represents an interest
in an underground or surface coal mining operation except as follows:

NONE

  ------ ----------------------------------------------------------------
  Code   Nature of Interests (e.g., employment, mineral rights, stock,
  J, S,  undeveloped land)
  C or R 

         
  ------ ----------------------------------------------------------------

I certify that the statements I have made are true, correct, and
complete to the best of my knowledge.

  ----------------------------------------------- -----------------------
  Signature of Employee                           Date

  ----------------------------------------------- -----------------------

**Part V. REVIEWERS CERTIFICATION.** Review completed and prohibited
interests, if any, have been resolved. Reviewer's comments, if any, show
the basis for the certification:

  ----------------------------------- -----------------------------------
  Signature of Reviewer               Date

  ----------------------------------- -----------------------------------

**PRIVACY AND PAPERWORK REDUCTION ACT NOTICES**

Section 517(g) of Public Law 95-87, the Surface Mining Control and
Reclamation Act, and 30 CFR 705, constitute the authority for collecting
the personal data on this statement of employment and financial
interests. This data must be furnished. Knowing failure to file or
report information required may subject you to disciplinary action by
your employing agency or other appropriate authority. Knowing failure to
file or report information required may also subject you to criminal
prosecution leading to a fine of not more than \$2,500 or imprisonment
for not more than one year or both.

The information gathered from the statement will be used to determine
whether there are any direct or indirect financial interests in
violation of Section 517(g) of Public Law 95-87.

Maintenance of the statement by the State regulatory authority is
subject to State law. Pursuant to 30 CFR 705 the statement may be
inspected by or provided to representatives of the U.S. Department of
the Interior.

If the statement is provided to the U.S. Department of the Interior, the
statement will be subject to the requirements of Federal law, including
the Privacy Act of 1974, 5 U.S.C. 552a. The U.S. Department of the
Interior may make routine disclosures: (1) from the records of an
individual in response to an inquiry from a Congressional office made at
the request of that individual; (2) to the U.S. Department of Justice
when related to litigation or anticipated litigation involving the
records or the subject matter of the records; and (3) to appropriate
State and Federal law enforcement agencies.

Public reporting burden for this form is estimated to average 20 minutes
per response, including time for reviewing instructions, gathering and
maintaining data, and completing and reviewing the form. You are not
required to respond to this collection of information unless it displays
a currently valid OMB control number. Direct comments regarding the
burden estimate or any other aspect of this form to the Information
Collection Clearance Officer, Office of Surface Mining Reclamation and
Enforcement, Room 210 SIB, 1951 Constitution Ave., NW, Washington, D.C.,
20240.