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

Office of Surface Mining Reclamation and Enforcement

State Employee Statement of Employment and Financial Interest

Approved by OMB

CN 1029-0067 

Expires: 8/31/2023 

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

3. Date of Appointment (in present position) 4. 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 that any of the required information is not known to you, but is known to another person (e.g., trustee, accountant, relative), request that

the other person submit the information on your behalf. Provide 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 a financial interest, including but not limited 

to: (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; and (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 

Code J, S, 

C or R

Name and Address of Organization Description of Interest

(e.g., employment, stock)

Nature of Employment and Financial 

Interest (e.g., salary, dividends)

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 residence means any real property used exclusively as a private 

dwelling. 

NONE 

Code J, S, 

C or R

Nature of Interests (e.g., ownership,

lease, royalty, mineral rights)

Description of Interest

(e.g., employment, stock)

Location of Interest

(county and state)

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 

Code J, S, 

C or R

Nature of Interests (e.g., ownership,

lease, royalty, mineral rights)

Description of Interest

(e.g., employment, stock)

Location of Interest

(county and state)

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 J, S, 

C or R

Nature of Interests (e.g., employment, mineral rights, stock, undeveloped land)

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. Systems of Records Notices (SORN) for statements of employment and financial interest is found at https://www.doi.gov/privacy/

osm_notices.

Public reporting burden for this form is estimated to average 5 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 4556 MIB, 1849 C Street., NW, Washington, D.C., 20240.