UNITED STATES DEPARTMENT OF AGRICULTURE

AGRICULTURAL MARKETING SERVICE

FEDERAL GRAIN INSPECTION SERVICE

COMPLIANCE DIVISION

CONFLICT OF INTEREST QUESTIONNAIRE

(NON-LICENSED OFFICIAL AGENCY PERSONNEL)

FORM APPROVED OMB NO. 0581-0309

According to the Paperwork Reduction Act of 1995, an agency 

may not conduct or sponsor, and a person is not required to 

respond to a collection of information unless it displays a valid 

OMB control number. The valid OMB control number for this 

information collection package is 0581-0309. The time required 

to complete this information collection is estimated to average 

5 minutes per response, including the time for reviewing 

instructions, searching existing data sources, gathering and 

maintaining the data needed, and completing and reviewing 

the collection of information.

1. Name (Print) (Last, First, Middle Initial)

2. Official Agency 3. Position or Relationship to Official Agency

Please indicate your answer to each of the following questions by entering an “X” in the appropriate space. If your answer to any 

questions is “YES”, or if you desire to elaborate on any of your answers, please describe your situation on the reverse of this from or 

on an additional page, if necessary.

4. Do you, your spouse, your minor children, or any blood relative

immediately residing in your household, serve as an officer,

director, committee member, or employee of any business entity

owning or operating any grain elevator or warehouse, or engage

in the merchandising, storage, commercial transportation, or

other commercial handling of grain?

5. Do you, your spouse, your minor children, or any blood relative

immediately residing in your household, have stock or other

financial interest, directly or indirectly, in any grain elevator or

warehouse or any other business entity involved in the

merchandising, storage, commercial transportation, or other

commercial handling of grain?

6. Do you know of any other matters, family relationships or other

personal relationships, which might give rise to an apparent or

possible conflict of interest involving your present employment

and any business entity described above?

YES NO

YES NO

YES NO

7. Signature 8. Date

PRIVACY ACT STATEMENT

Mandatory response to the above Conflict of Interest Questionnaire is required by 7 U.S.C. 87 Section 11. Failure to

provide information may result in the Official Agency not receiving Federal designation/delegation as an Official Agency.

Information will be used to evaluate/resolve possible conflicts of interest an also may be referred the Department of Justice

or to other investigative and law enforcement agencies for investigation, prosecution, and/or administrative action resulting

from violation of law, rule, regulation, instruction, or order; or to a Congressional office in response to a constituents

request for release of his/her record. 18 U.S.C. 1001 provides for a fine of not more than $10,000 or imprisonment for not

more than 5 years, or both, for false or fraudulent statements made to an agency of the United States.

Form FGIS-100 (01/24) Previous editions are obsolete. Expires 03-25
Instructions for Completing FGIS-100 

Please type application or print carefully. Additional sheets may be used to describe your situation, if 

necessary.

1. Provide the name of the individual non-licensed employee of an official agency.

2. Provide the name of the official agency that employs the individual.

3. Provide the name of the position or organizational title in the official agency.

4. Check the block left of “YES” if true; check in the block left of “NO” if not true.

5. Check the block left of “YES” if true; check in the block left of “NO” if not true.

6. Check the block left of “YES” if true; check in the block left of “NO” if not true.

7. Sign full name.

8. Provide date signed.

Contact Information

Submit with an Application for Designation (Form FGIS - 942) or upon any change in non-licensed

personnel. Send using any of the following methods:

• E-mail: Send via electronic mail to FGISQACD@ams.usda.gov

• Hand Delivery, Courier, or Mail to:

Quality Assurance & Compliance Division, AMS, FGIS, USDA

1400 Independence Avenue, SW., Room 2409-S; STOP 3630

Washington, DC 20250

For further information contact:

Director 

Quality Assurance & Compliance Division

1400 Independence Avenue, SW, Room 2409-S 

Washington, DC 20250 

Telephone: (202) 720-0228

Email: FGISQACD@ams.usda.gov

AMS website: http://www.ams.usda.gov