Dd Form 2945 – Fill Out and Use This PDF

The public reporting burden for this collection of information is estimated to average 1 hour 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. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing the burden, to the Department of Defense, Washington Headquarters Services, Executive Services Directorate, Information Management Division, 4800 Mark Center Drive, Alexandria, VA 22350-3100 (0704-0467). Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number.

PLEASE DO NOT RETURN YOUR FORM TO THE ABOVE ORGANIZATION.

SECTION I - CONTACT INFORMATION

SECTION II - SERVICE INFORMATION

OTHER (Specify as Non Career SES, schedule C, IPA, HQE, SGE)

c.IF A POLITICAL APPOINTEE, HAVE YOU MADE OTHER ETHICS COMMITMENTS? (If yes, provide detail: did you receive a waiver, or do you anticipate work as a lobbyist)

SECTION III - PRIOR ETHICS INFORMATION

16. PRIOR ETHICS ADVICE

a. HAVE YOU RECEIVED ANY ETHICS ADVICE OR OPINION FROM ANOTHER GOVERNMENT ETHICS OFFICIAL CONCERNING YOUR

17.FINANCIAL DISCLOSURE

a. IN THE LAST 2 YEARS, HAVE YOU FILED A FINANCIAL DISCLOSURE REPORT?

SECTION III - PRIOR ETHICS INFORMATION (Continued)

18.LICENSED ATTORNEY: PLEASE INDICATE IF YOU ARE A LICENSED ATTORNEY, EVEN IF YOU ARE NOT EMPLOYED AS AN ATTORNEY BY DOD.

SECTION IV - DOD POSITION INFORMATION

19.POSITIONS HELD AND MAJOR DUTIES: IN WHAT AGENCIES OR ORGANIZATIONS HAVE YOU SERVED DURING YOUR LAST 5 YEARS OF DEPARTMENT OF DEFENSE SERVICE? For each position, describe your job or briefly describe your major duties during the last 5 years, focusing on supervisory duties and official responsibility requirements relating to defense contracts,especially related to prospective employers, any aspect of the acquisition process, such as requirements development, acting as program manager, deputy program manager or contracting officer, or otherwise involved in the contracting process. Identify names of projects, program, contractors and subcontractors.)

(3) DESCRIPTION

(4) POSITION HELD:

(4) POSITION HELD:

(4) POSITION HELD:

SECTION IV - DOD POSITION INFORMATION (Continued)

20.HAVE YOU SERVED IN ANY OF THE FOLLOWING POSITIONS OR PERSONALLY TAKEN ONE OF THE FOLLOWING ACTIONS REGARDING AN ACQUISITION OR CONTRACT IN EXCESS OF $10 MILLION?

g.IF YOU ANSWERED "YES" TO ANY OFTHESE QUESTIONS, IDENTIFY THE CONTRACT(S) IN WHICH YOU PERFORMED THAT FUNCTION

(List contract number(s), title(s) and date(s) of last action and summarize your duties/responsibilities related to that contract.)

SECTION V - PROSPECTIVE EMPLOYER INFORMATION

22. CONFLICT OF INTEREST

a.HAVE YOU TAKEN ANY ACTION TO RESOLVE A POTENTIAL CONFLICT OF INTEREST RELATED TO SEEKING EMPLOYMENT EFFORTS, INCLUDING ISSUING A WRITTEN DISQUALIFICATION, CHANGING JOBS, HAD YOUR DUTIES CHANGED, OR TAKEN ANY OTHER ACTION TO

23.WITH WHOM ARE YOU SEEKING EMPLOYMENT?

24.WHAT ACTIONS HAVE YOU TAKEN CONCERNING YOUR FUTURE EMPLOYMENT (i.e., sent out resume, interview, filed disqualification, accepted a position)?

25.DESCRIBE ANY OFFICIAL INVOLVEMENT WITH OR DUTIES YOU HAVE HAD RELATED TO PROSPECTIVE EMPLOYERS LISTED IN BLOCK 23.

26.FUTURE JOB TITLE

a.JOB TITLE

b.JOB DESCRIPTION (Include information on how this may relate to your Government duties.)

27.START DATE: WHEN DO YOU PLAN TO START YOUR NEW EMPLOYMENT? (MM/DD/YYYY)

31. ADDITIONAL COMMENTS

INSTRUCTIONS FOR COMPLETING DD FORM 2945

DD FORM 2945 INSTRUCTIONS, JUL 2013

PRIVACY ACT STATEMENT

AUTHORITY: 41 U.S.C. 2104; 5 C.F.R. 2635.107, Joint Ethics Regulation.

PRINCIPAL PURPOSE(S): To enable ethics officials to render ethics advice to military and civilian employees leaving Government service. When completed, records are covered by OGE/GOVT-1, http://dpclo.defense.gov/privacy/SORNs/govt/OGEGOVT-1.html.

ROUTINE USE(S): To disclose the information furnished by the reporting official, in accordance with provisions of section 105 of the Ethics in Government Act of 1978, as amended, to any requesting person.

a.To disclose, in accordance with section 105 of the Ethics in Government Act, as amended, and subject to the limitations conntained in section 208(d)(1) of title 18, U.S.C., any determination granting an exemption pursuant to 208(b)(1) or 208(b)(3) of title 18, U.S.C., to any requesting person.

b.To disclose pertinent information to the appropriate Federal, State, or local agency responsible for investigating, prosecuting, enforcing, or implementing a statute, rule, regulation, or order, where the disclosing agency becomes aware of an indication of violation or potential violation of civil or criminal law or regulation.

c.To disclose information to another Federal agency, to a court, or a party in litigation before a court or in an administrative proceeding being conducted by a Federal agency, either when the Government is a party to a judicial or administrative proceeding or in order to comply with a subpoena issued by a judge of a court of competent jurisdiction.

d.To disclose information to any source when necessary to obtain information relevant to a conflict-of-interest investigation or determination.

e.By the National Archives and Records Administration or the General Services Administration in records management inspections conducted under authority of 44 U.S.C. 2904 and 2906.

f.To disclose information to the Office of Management and Budget at any stage in the legislative coordination and clearance process in connection with private relief legislation as set forth in OMB Circular No. A-19.

g.To disclose information to the Department of Justice, or in a proceeding before a court, adjudicative body, or other administrative body before which OGE is authorized to appear, when: OGE, or an employee of OGE in his or her official capacity, or any employee of OGE in his or her individual capacity (where the Department of Justice or OGE has agreed to represent the employee); or the United States (when OGE determines that litigation is likely to affect OGE), is a party to litigation or has an interest in such litigation, and the use of such records by the Department of Justice or OGE is deemed by OGE to be relevant and necessary to the litigation provided, however, that the disclosure is compatible with the purpose for which such records were collected.

h.To disclose the public financial disclosure report and any accompanying documents to reviewing officials in a new office, department or agency when an employee transfers or is detailed from a covered position in one office, department or agency to

acovered position in another office, department or agency.

i.To disclose information 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.

j.To disclose information to contractors, grantees, experts, consultants, detailees, and other non-Government employees performing or working on a contract, service, or other assignment for the Federal Government, when necessary to accomplish an agency function related to this system of records.

NOTE: When DoD is requested to furnish such records to the Director or other authorized officials of the Office of Government Ethics (OGE), such a disclosure is to be considered as made to those officers and employees of the agency which co-maintains the records who have a need for the records in the performance of their official duties in accordance with the Ethics in Government Act of 1978, 5 U.S.C. app., and other ethics-related laws. Executive orders and regulations conferring pertinent authority on OGE, pursuant to the provision of the Privacy Act at 5 U.S.C. 552a(b)(1).

The DoD "Blanket Routine Uses" found at http://dpclo.defense.gov/privacy/SORNs/blanket_routine_uses.html may apply to these records. Any release under a blanket routine use will be compatible with the purpose of the collection.

DISCLOSURE: Voluntary; however, failure to fully disclose information requested may result in receipt of incomplete advice or inability to provide written advice. This may result in a delay in being hired by a Department of Defense contractor or receipt of compensation from such contractor. Failure to comply may also result in the imposition of administrative penalties in accordance with 41 U.S.C. 2105(c).

DD FORM 2945 INSTRUCTIONS (BACK), JUL 2013