A Certificate of Divestiture issued pursuant to the provisions of this subpart is available to the public in accordance with the rules of Sec. 2634.603 of this part.
Sec. Appendix A to Part 2634--Certificate of Independence (Form
Approved: OMB Control No. 3209-0007)
The Certificate of Independence required by Sec. 2634.405(d)(2) shall be executed as follows:
Certificate of Independence
With respect to the trust of ____ (Settlor), which has been submitted to the Office of Government Ethics for certification pursuant to the Ethics in Government Act of 1978 (Pub. L. 95-521, as amended), the undersigned proposed [Trustee] [____] of such trust is a financial institution which is eligible to serve in such fiduciary capacity in accordance with section 102(f)(3)(A) of such Act:
FIRST: The undersigned is (check one)--
( ) a bank, as defined in 12 U.S.C. 1841(c), or
( ) an investment adviser, as defined in 15 U.S.C. 80b-2(a)(11), not more than 10 percent of which is owned or controlled by a single individual.
SECOND: The undersigned--
(1) Is independent of and unassociated with any interested party so that the undersigned cannot be controlled or influenced in the administration of the trust by any interested party; and
(2) is not and has not been affiliated with any interested party, and is not a partner of, or involved in any joint venture or other investment or business with any interested party.
THIRD: Any director, officer, or employee of the undersigned--
(1) Is independent of and unassociated with any interested party so that such director, officer, or employee cannot be controlled or influenced in the administration of the trust by any interested party;
(2) Is not and has not been employed by any interested party, nor a director, officer, or employee of any organization affiliated with any interested party, and is not and has not been a partner of, or involved in any joint venture or other investment or business with, any interested party; and
(3) Is not a relative of any interested party.
FOURTH: The undersigned certifies that the statements contained herein are true, complete and correct to the best of such undersigned's knowledge and belief.
Date___
(firm)___
By:___
(title)___
Note: See Appendix C of this part for Privacy Act and Paperwork Reduction Act notices. [57 FR 11829, Apr. 7, 1992, as amended at 63 FR 58620, Nov. 2, 1998; 77 FR 39150, July 2, 2012] Sec. Appendix B to Part 2634--Certificate of Compliance (Form Approved:
OMB Control No. 3209-0007)
The Certificate of Compliance required by Sec. 2634.408(d)(4) shall be executed as follows:
Certificate of Compliance
With respect to the qualified blind trust (qualified diversified trust) of___ (Settlor), the undersigned, the approved [Trustee] [___] of such trust, pursuant to 5 CFR 2634.405, has served in such fiduciary capacity during the calendar year [or for the period beginning___ and ending___] and is eligible to continue in such capacity by virtue of the following:
FIRST: The undersigned (and any director, officer, or employee) has not knowingly or negligently, and will not--
(A) disclose any information to an interested party with respect to the trust that may not be disclosed pursuant to title I of the Act, the implementing regulations (including 5 CFR 2634.408(d)(1)(i)), or the trust instrument;
(B) acquire any holding the ownership of which is prohibited by, or not in accordance with, applicable statute, regulation, or the terms of the trust instrument;
(C) solicit advice from any interested party with respect to such trust, which solicitation is prohibited by title I of the Act, the implementing regulations (including 5 CFR 2634.408(d)(1)(iii)), or the trust instrument;
(D) fail to file any document required by title I of the Act, the implementing regulations (5 CFR 2634.408), or the trust instrument; or
(E) violate or fail to comply with any provision or requirement of title I of the Act, the implementing regulations, or the trust instrument.
SECOND: The undersigned (and any director, officer, or employee) will not knowingly or negligently engage in the above-mentioned activities.
THIRD: The undersigned certifies that the statements contained herein are true, complete and correct to the best of such undersigned's knowledge and belief.
Date___
(firm)___
By:___
(title)___
Note: See appendix C of this part for Privacy Act and Paperwork Reduction Act notices. [57 FR 11830, Apr. 7, 1992; 57 FR 21855, May 22, 1992, as amended at 77 FR 39150, July 2, 2012]
Sec. Appendix C to Part 2634--Privacy Act and Paperwork Reduction Act
Notices for Appendixes A and B
Privacy Act Statement
Section 102(f) of the Ethics in Government Act of 1978 as amended (the ``Ethics Act'') (5 U.S.C. App.) and subpart D of 5 CFR part 2634 of the regulations of the Office of Government Ethics (OGE) require the reporting of this information for the administration of qualified trusts under the Ethics Act. The primary use of the information on this certificate is for review by Government officials of OGE and the agency of the Government employee for whom the trust is established to determine compliance with applicable Federal laws and regulations as regards qualified trusts. Additional disclosures of the information on this certificate may be made:
(1) to any requesting person in accordance with the access provisions of section 105 of the Ethics Act;
(2) to a Federal, State or local law enforcement agency if the disclosing agency becomes aware of a violation or potential violation of law or regulation;
(3) 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;
(4) to a source when necessary to obtain information relevant to a conflict of interest issue;
(5) to the National Archives and Records Administration or the General Services Administration in records management inspections;
(6) to the Office of Management and Budget during legislative coordination on private relief legislation; and
(7) in response to a discovery request or for the appearance of a witness in a pending judicial or administrative proceeding, if the information is relevant to the subject matter. Knowing or willful falsification of information on this certificate or failure to file or report information required to be reported under title I of the Ethics Act and 5 CFR part 2634 of the OGE regulations may lead to disqualification as a trustee or other fiduciary as well as possible disqualification of the underlying trust itself. Knowing and willful falsification of information required under the Ethics Act and the regulations may also subject you to criminal prosecution.
Public Burden Information and Paperwork Reduction Act Statement
This collection of information is estimated to take an average of twenty minutes per response. You can send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: Deputy Director for Administration and Information Management, U.S. Office of Government Ethics, Suite 500, 1201 New York Avenue, NW., Washington, DC 20005-3917. Do not send your completed certificate to that official; rather, send it to the Director of the Office of Government Ethics at that address as provided in the part 2634 regulation.
Pursuant to the Paperwork Reduction Act, as amended, an agency may not conduct or sponsor, and no person is required to respond to, a collection of information unless it displays a currently valid OMB control number (that number, 3209-0007, is displayed here and in the headings of the OGE model qualified trust certificates of independence and compliance, appendixes A and B to this part 2634). [57 FR 11830, Apr. 7, 1992, as amended at 63 FR 58620, Nov. 2, 1998; 67 FR 22349, May 3, 2002]