Oge Form 278 – Fill Out and Use This PDF

ＲＪＨ＃Ｉｒｕｐ＃５：；＃＋Ｕｈｙ１＃12２５３４1，

Executive Branch Personnel PUBLIC FINANCIAL DISCLOSURE REPORT

Form Approved:

８＃Ｆ１Ｉ１Ｕ１＃Ｓｄｕｗ＃５９６７＃

OMB No. 3209 - 0001

Ｘ１Ｖ１＃Ｒｉｉｌｆｈ＃ｒｉ＃Ｊｒｙｈｕｑｐｈｑｗ＃Ｈｗｋｌ＃ｆｖ＃

DateofAppointment,Candidacy,Election,

Reporting

Incumbent

Calendar Year

New Entrant,

Termination

TerminationDate(IfAppli-

Fee for Late Filing

orNomination(Month,Day,Year)

Status

Covered by Report

Nominee, or

Filer

cable)(Month,Day,Year)

Any individual who is required to file

(Check Appropriate

Candidate

this report and does so more than 30 days

Boxes)

after the date the report is required to be

Last Name

First Name and Middle Initial

Reporting

filed, or, if an extension is granted, more

Individual's Name

than 30 days after the last day of the

filing extension period, shall be subject

Title of Position

Department or Agency (If Applicable)

to a $200 fee.

Position for Which

Reporting Periods

Filing

Incumbents: The reporting period is

Location of

Address (Number, Street, City, State , and ZIP Code)

Telephone No. (Include Area Code)

the preceding calendar year except Part

II of Schedule C and Part I of Schedule D

Present Office

where you must also include the filing

(or forwarding address)

year up to the date you file. Part II of

Title of Position(s) and Date(s) Held

Schedule D is not applicable.

Position(s) Held with the Federal

Government During the Preceding

Termination Filers: The reporting

12 Months (If Not Same as Above)

period begins at the end of the period

covered by your previous filing and ends

at the date of termination. Part II of

Presidential Nominees Subject

Name of Congressional Committee Considering Nomination Do You Intend to Create a Qualified Diversified Trust?

Schedule D is not applicable.

to Senate Confirmation

Yes

No

Nominees, New Entrants and

Candidates for President and

Certification

Signature of Reporting Individual

Date (Month, Day, Year)

Vice President:

I CERTIFY that the statements I have

Schedule A--The reporting period

madeonthisformandallattached

for income (BLOCK C) is the preceding

schedulesaretrue,completeandcorrect

calendar year and the current calendar

tothebestofmyknowledge.

year up to the date of filing. Value assets

OtherReview

Signature of Other Reviewer

Date (Month, Day, Year)

as of any date you choose that is within

31 days of the date of filing.

(Ifdesiredby

agency)

Schedule B--Not applicable.

AgencyEthicsOfficial'sOpinion

Signature of Designated Agency Ethics Official/Reviewing Official

Date (Month, Day, Year)

Schedule C, Part I (Liabilities)--The

reporting period is the preceding calendar

On the basis of information contained in this

year and the current calendar year up to

any date you choose that is within 31 days

report, I conclude that the filer is in compliance

with applicable laws and regulations (subject to

of the date of filing.

any comments in the box below).

Office of Government Ethics

Signature

Date (Month, Day, Year)

Schedule C, Part II (Agreements or

Arrangements)--Show any agreements or

Use Only

arrangements as of the date of filing.

Schedule D --The reporting period is

Comments of Reviewing Officials (If additional space is required, use the reverse side of this sheet)

the preceding t w o calendar years and

the current calendar year up to the date

of filing.

(Check box if filing extension granted & indicate number of days

)

Agency Use Only

Reporting Individual's Name

SCHEDULE A continued

Page Number

Part II: Gifts, Reimbursements, and Travel Expenses

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