EPA Form 3110-48 ( 8

- 11 ) 

### 1 Confidential Financial Disclosure Form for Environmental Protection

A g enc y Special Government Emplo y ees (EPA Form 3110-48)

A. Why You Must File Public service is a public trust. In order to uphold that trust, the Government must obtain certain confidential financial information to ensure that there are no conflicts between your public service and your private interests.

B. Who Must File This form is used by the Agency for Special Government Employees (SGEs) as defined under 18 U.S.C. 202 and candidates

to be SGEs.

C. Privacy Act Statement Title I of the Ethics in Government Act of 1978 (5 U.S.C. App.), Executive Order 12674 (as modified by Executive Order 12731), and 5 CFR Part 2634, Subpart I, of the Office of Government Ethics regulations require the reporting of this informatio n. The primary use of the information on this form is for review by Government officials of your agency, to determine compliance with applicable Federal conflict of interest la ws and regulations. Additional disclosures of the information on this report may be m ade: (1) to a Federal, State, or local law enforcem ent agency if the disclosing agency becomes aware of a violation or potential violati on of law or regulation; (2) to a court or party in a court or Federal administrative proceeding if the Government is a party or in order to comply with a judge-issued subpoena; (3) to a source when necessary to obtain information relevant to a conflict of interest investiga tion or decision; (4) to the National Arch ives and Records Administration or the General Services Administration in records management inspections; (5) to the Office of Management and Budget during legislative coordination on private relief legislation; (6) to t he Department of Justice or in certain legal proceedings when the disclosing agency, and employee of the disclosing agency, or the United States is a party to litigation or has an interest in the litigation and the use of such records is deemed relevant and necessary to the litigation; (7) to reviewing officials in a new office, department or agency when an employee transfers from one covered po sition to another, (8) to a Member of Congress or a congressional office in response to an inquiry made on behalf of an individual who is the subject of the record, and (9) to contractors and other non-Government employees working for the Federal Government to accompli sh a function related to an OGE Government-wide system of records. This confidential report will not be disclosed to any requestin g person unless authorized by law.

D. Paperwork Burden Disclosure Notice The public reporting and recordkeeping burden for this coll ection of information is estimated to average one hour per response. Send comments on the Agency’s n eed for this information, the accuracy of the provided burden estimates, and any suggested methods for minimizing respondent burden, including thro ugh the use of automated collection techniques to the Directo r, Collection Strategies Division, U.S. Environmental Protectio n Agency (Mail Code 2822T), 1200 Pennsylvania Ave., NW, Washington, D.C. 20460. Include the OMB control number in any correspondence. Do not send the completed form to that address; instead, send your completed form as directed by the Agency official who sent it to you.

E. When to file Candidates and newly-appointed special Government employees must fully complete this form before performing any work for EPA. Subsequently, you must file a new form annually or as instructed by your agency ethics official. PLEASE NOTE: It is your responsibility to notify the appropriate EPA ethics official of any changes to the information you provide in this form.

F. Where to file Send your report to the address specified by the Agency or by the Agency ethics official. You may use additional blank pages in any section if needed. Please note your name and supplemental page number on the continuation pages.



### Penalties

Falsification of information or failure to file or report information required to be reported may subject you to disciplinary action by your employing agency or other authority. Knowing and willful falsification of information required to be repor ted may also subject you to criminal prosecution.EPA Form 3110-48 ( 8-11 ) 

### 2 G. What is a Special Government Employee (SGE)? The SGE category was created by Congress to employ individuals who provide important, but limited, service to the Government. These employees are subject to a limited set of conflict of interest requ irements. SGEs provide temporary service to the Government (not to exceed 130 days during any period of 365 consecutive days with or without compensation). SGEs are often recruited because they provide outside expertise or perspectives that might be unavailable among an agency's regular employees. SGEs are generally used as advisory committee members, individual experts or consultants. However, some SGEs serve on Boards or Commissions and are brought on pursuant to applicable statute. (See 18 U.S.C. §202(a) for more information.)

H. What is a conflict of interest? 18 U.S.C. §208 prohibits all employees (including SGEs) from participating in any particular Government matter that will have a direct and predictable effect on their financial interests. It also prohibits employees from acting in Government matter s that will

affect the financial interests of others with whom th ey have certain relationships. These relationships are:

• Spouse

• Minor child

• General partner

• Organization in which the individual serves as officer, director, trustee, general partner or employee

• Person or organization with which the employee is negotiating or has an arrangement concerning prospective employment.

I. What is a particular matter? The term "particular matter" includes deliberations, decisions, or actions that are focused upon the interests of specific persons or entities or an identifiable class of persons or entities. A particular matter does not extend to broad policy option s or considerations directed toward the interest of a large and dive rse group of people. A particular matter may involve specific pa rties (e.g., a contract, grant or case in litigation) or it may be a pa rticular matter of general applicability that is focused on th e interests of a discrete and identifiable class of persons (such as an industry).

J. What is a direct and predictable effect? A particular matter will have a direct effect on a financial in terest if there is a close caus al link between any decision or action to be taken in the matter and any expected effect of the matter on the financial interest. However, a particular matter will no t have a direct effect on a financial interest if the link is attenuated, or is contingent upon the occu rrence of events that are specul ative, or that are independent of, and unrelated to, the matter. Furthermore, a pa rticular matter that has an effect on a financial interest o nly as a consequence of its effects on the general eco nomy is also not considered to have a direct effect on a financial interest. A pa rticular matter will have a "predictable" effect if there is a real (as opposed to speculative) possibility that the matter will affect a financial interest. It is not necessary to know the magnitude of the loss/gain, and the dollar amount is immaterial.

K. What is an appearance of a loss of impartiality? 5 C.F.R. Part 2635, Subpart E contains provisions intended to ensure that an employee takes appropriate steps to avoid an appearance of a loss of impartiality in the performance of his/he r official duties. Where an empl oyee knows that a particular m atter involving specific parties is likely to have a direct and predicta ble effect on the financial interest of a member of his/her h ousehold, or knows that a person with whom he/she has a covered relationship is or represents a party to such a matter, and where the person determines that the circumstances would cause a reasonable person with knowledge of the relevant facts to question his/her impartiality in the matter, the employee should not participate in the matter unless he/she has informed the agency designee of the appearance of a problem and received au thorization from the agency designee.EPA Form 3110-48 ( 8

- 11 ) 

### 3 SECTION 1: Identifying Informatio n and Record of Agency Review

Your Name:

Last Name: First Name: Middle Initial:

Your Certification:

I certify that information I have provided on this form and all attachments is true, complete and correct to the best of my kno wledge.

Signature of Reporting Individual Date:

Date Received by the Agency (for Agency use only):

Agency Review (for Agency use only):

Panel Name/Employing

Office

Intermediate Reviewer Signature, Date Final Reviewing Official Signature, Date

Comments:

Panel Name/Employing

Office:

Intermediate Reviewer Signature, Date Final Reviewing Official Signature, Date

Comments:

Panel Name/Employing

Office:

Intermediate Reviewer Signature, Date Final Reviewing Official Signature, Date

Comments:

Panel Name/Employing

Office:

Intermediate Reviewer Signature, Date Final Reviewing Official Signature, Date

Comments:EPA Form 3110-48 ( 8-11 ) 

### 4 SECTION 2: Your Employmen t/Consulting/Volunteer Work

Report any employment or consulting, whether or not for compen sation, for you and/or your spouse for the last two years precedi ng the date of filing. Do not include any compensated expert te stimony as these are reported in another part of this form. Don’t forget to include your current employer as well as your spouse’s employer. You may indicate (S) for employment of your spouse. You should report any of the following positions that you hold, whet her or not for compensation: employee, officer, director, trus tee, general partner, proprietor, representative/executor of any busi ness, consulting firm, non-profit, labor organization, or educa tional institution. Also include any organization or person with whom you are negotiating or have an arrangement concerning prospecti ve employment. You may exclude unpaid positions with any religious , social, fraternal or political entities, or those solely of a n honorary nature, but you have to include an y positions held with profe ssional societies. You may add additional pages as neces sary. If you have NO employment at all, enter NONE below

.

Organization (Name, City, State). If reporting consulting, Name of Project and Client. Name of position and description of work. If you ar e employed by a consulting firm, indicate the firm’s major practice areas, categories of principal clients, an d the clients you or your spouse have dealt with directly or derived compensation from. If reporting independent consulting, provide a description and date(s) of the project. Example: East-West University, Anywhere,

KS Example: Dean, School of Environmental Studies.

Example: ABC Corporation, Smallville,

VA Example: Consultant on toxicological effects of heavy metals in wastewater from company facilities. July 2007-July 2011.EPA Form 3110-48 ( 8-11 ) 

### 5 Continuation of Section 2 (if needed). Otherwise, continue to Section 3

Organization (Name, City, State). If reporting consulting, Name of Project and Client. Name of position and description of work. If you ar e employed by a consulting firm, indicate the firm’s major practice areas, categories of principal clients, an d the clients you or your spouse have dealt with directly or derived compensation from. If reporting independent consulting, provide a description and date(s) of the project.EPA Form 3110-48 ( 8-11 ) 

### 6 SECTION 3: Compensated Expert Testimony

Report any expert testimony for you or your spouse for the last two y ears preceding the date of filin g. You may indicate (S) f or

spouse. If you have NO compensated expe rt testimony, enter “NONE” below.

Client Name, City, State Description & Date of Testimony. Include citation if available.

Example: XYZ law firm, Anytown, CA Example: Provided expert testimony for ABC corpor ation (plaintiff) on effects of heavy metals in wastewater from company facilities. ABC Co rporation v. XYZ, Civil Action No. 07-1234, Superior Court of Anywhere, July, 2007.EPA Form 3110-48 ( 8-11 ) 

### 7 SECTION 4: Research Support/Project Funding

Report any source of research or project funding (e.g., grants, contracts, or other mechanism) that you or your spouse have re ceived in the last two years preceding the date of filing from any source (including state, federal or local government, private sector c ompanies, or non-profit organizations). You may indi cate (S) for research support or project funding received for your spouse. Add any additional pages as necessary. If you have NO research support or project funding, enter “NONE” below.

Funding Organization (Name, City, State) If EPA, include

Office Exact Title of Project. Include start and completion dates. Please also indicate whether funded through grant, cooperative agreement, or contract. If a grant, include whether awarded competitively or not. If an EPA grant include Project Officer and grant number.

Example:

Foundation for a Cleaner Tomorrow, Washington, DC Example: Competitive Grant: “Mitigation Technologies for Volatile Organic Compounds” July 2007-July

2011.

Example: EPA,

Office of Research and Development, Cincinnati, OH Example: Competitive Grant: “Health Effects of Long-Term Exposure to Air Pollutants in Nonsmoking Virginia Residents” Project Officer: Jane Doe. EPA Grant Number R123456. March 2000 – Feb. 2003EPA Form 3110-48 ( 8-11 ) 

### 8 SECTION 5: Assets

Report for yourself, spouse, and dependent children any assets currently held for investment that are valued at more than $1,00 0 or that generate more than $200 per year in income. You may dis tinguish any entry for a family member by preceding it with (S) fo r spouse, (DC) for dependent child, or (J) for jointly held. You may also add additional pages if needed. If you have NO reportable assets, enter “NONE” below.

Types of assets to report include (but are not limited to):

• Stocks, bonds, annuities, trust holdings, partnership interests, lif e insurance, investment real estate or a privately-held tra de or business. For real estate or a privately held busin ess, report the type and city/state of the entity.

• Sector mutual funds, which are funds invest ed in a particular industry, business, or location such as ABC Electronics Fund or XYZ Canada Fund. Please report the full name of the fund, not just the general family fund name.

• Individual holdings of retirement plans like 401(k)s or IRAs. List each holding except diversified mutual funds (see below)

• Holdings of investment life insurance or variable annuities

• Defined benefit pension plans (include name of employer)

Do NOT report:

• Certificates of deposit, savings accounts or checking accounts or any deposit in a bank, credit union or similar financial

institution

• Term life insurance

• Money market mutual funds or money market accounts

• Your personal residence (unless you rent it out)

• Diversified mutual funds, such as ABC Equity Value Fund or XYZ Large Capital Fund

• U.S. Government securities (e.g ., treasury bonds, treasury bills , treasury notes, U.S. savings bo nds or any securities issued b y U.S. Government agencies or Government sponsored corporations such as the Tennessee Valley Authority)

• Money owed to you, your spouse, or dependent child by a spouse, parent, sibling, or child

• Social Security Benefits

• Federal Government salary or retirement benefits

• Veterans’ benefits

• Alimony

• Child Support

• Underlying holdings of a trust that was not created by you, your spouse or dependent children and for which you, your spouse and dependent children have no past or present knowledge of the holdings or sources of income

Definitions:

Dependent Child: A son, daughter, stepson or stepdaughter who is either: (1) unmarried and under age 21 and living in the filer’s house, or (2) considered dependent under the U.S. tax code.

Diversified Mutual Fund: A mutual fund that does not have a policy of concentrating its investments in an industry, business, single country other than the United States or si ngle state within the United States.

Full Name of Asset. Include stock ticker symbol or other identifying information as appropriate.

Example: DEF Corporation (DEFC)

Example: JKL Energy Fund (JKLE)EPA Form 3110-48 ( 8-11 ) 

### 9 Continuation of Section 5 (if needed). Otherwise, continue to Section 6.

Full Name of Asset. Include stock ticker symbol or other identifying information as appropriate.EPA Form 3110-48 ( 8-11 ) 

### 10 SECTION 6: Supplemental Ethics Questions for Speci al Government Employees Serving on Advisory

Panel/Committees/Subcommittees

If you are serving or are a candidate to serve on an advisory panel/committee/subcommittee, pl ease answer the following questio ns:

Do you know of any reason that you might be unable to provide impartial advice on the matter to come before the panel/committee/subcommittee or any reason that your impartiality in the matter might be questioned?

Have you had any previous involvement with the review document (s) under consideration including authorship, collaboration with the authors, or previous peer review functions? If so, please identify and describe that involvement.

Have you served on previous advisory panels, committees or subcommittees that have addressed the topic under consideration? If so, please identify those activities.

Have you made any public statements (written or oral) on the issue that would indicate to an observer that you have taken a pos ition

on the issue under consideration? If so, please identify those statements.

You may attach extra sheets if needed.