Fillable U.S. COMMISSION ON CIVIL RIGHTS (U.S. Commission on Civil Rights)

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U.S. COMMISSION ON CIVIL RIGHTS (U.S. Commission on Civil Rights)

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U.S. COMMISSION ON CIVIL RIGHTS
Confidential Conflict-of-Interest Statement for USCCR State Advisory Committee Members
Name of Advisory Committee:
Member’s name:
Member’s address:
In carrying out your duties as a member of a USCCR advisory committee, you will be called upon to give advice on civil rights issues policy deliberations. Sometimes policy
deliberations focus on the interests of specific persons or organizations or on a discrete class of specific persons or entities. In such cases, your personal financial interest or your
affiliations or relationships with other affected persons or entities may raise conflict-of-interest questions. By providing the information requested on this form, you will satisfy a
requirement of U.S. Office Government Ethics regulations and help USCCR personnel identify and resolve potential and apparent conflicts. You must return your completed
statement to the Committee Designated Federal Officer responsible for the Committee prior to participating in Committee activity.
For each of the three parts below list all interests, positions, arrangements, or relationships you think might reasonably be responsive. If you have none, check the “NONE” box.
Part I: Financial Interests
If you, your spouse, or your dependent children receive any income (compensation, honoraria, royalties, etc.), hold any stock, securities, or similar financial interests in any
nongovernmental entity that could be affected by civil rights policy deliberations likely to come before the Committee – list all such interests.
EX
AMPLE: Does your spouse hold stock in a company that could be affected by a change in USCCR civil rights projects?
NONE [ ]
(Identify specific business, stock, bond, etc.)
1.
2.
3.
4.
5.
Part 2: Positions and Arrangements
If any entity with which (i) you are now “connected”, (ii) you are negotiating to become “connected”, or (iii) you have arrangement to become “connected” in the future has
financial interests that could be affected by policy deliberations likely to come before the Committee – describe all such interests. You are “connected” with any entity if you
serve as an employee, officer, director, trustee, general partner, agent attorney, consultant, or contractor for that entity.
EX
AMPLE: (1) Are you connected with a professional association, or corporation, that has a contract, or other financial relationship
with the U.S. Commission on Civil Rights or parties that may be affected by recommendations of the Committee
(i.e. recommendation for civil rights project, or selection of one type of research over another, etc.)? If so, name the other
entity and contract or other financial relationship involved.
NONE [ ]
(Identify specific organization, or entity)
(Type of position, arrangement or other connection
(Interest or issue involved)
1.
2.
3
4
CCR Form 17 (June 2017)
Part 3: Other Interests or Relationships
Are you aware of any other interests, affiliations, or relationships you believe would impair your impartiality in any policy deliberations likely to come before the Committee, or
that would cause a reasonable person with knowledge of the relevant facts to question your impartiality in such matter?
EXAMPLE: Does your best friend stand to benefit by a change in the U.S. Commission on Civil Rights administration of a program your committee is advising? If so, briefly
describe. NONE [ ]
1.
2.
3.
4.
5.
6.
7
COMMITTEE MEMBER’S CERTIFICATION
I certify that my answers to the above questions are true to the best of my knowledge. I also understand that I must contact the U.S. Commission on Civil Rights Designated
Federal Official responsible for the Committee if a conflict exists or arises during my term of service.
Member’s Name (Please Print) Signature Date
CERTIFICATION BY RESPONSIBLE USCCR OFFICIAL
On the basis of the information contained in this report, I conclude that the filer is in compliance with the applicable laws and regulations, except as noted below.
Signature Date
Privacy Act Statement
required by section (e)(3) of the Privacy Act
Title I of the Ethics in Government Act of 1978 (5 U.S.C. App.), Executive Order 12674, and 5 CFR Part
2634, Subpart I, of the Office of Government Ethics regulations require the reporting of this information
before you may serve on a Federal advisory committee. The primary use of the information on this form is for
review by officials of any agency, to determine compliance with applicable Federal conflict of interests laws
and regulations. This confidential report will not be disclosed to any requesting person unless authorized by
law. Failure to file this form will preclude your service on the advisory committee. Knowing and willful
falsification of information required to be reported could subject you to criminal prosecution.
CCR Form 17 (June 2017)
.
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Completed 19 July 2020

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