Annual Report 2019   U.S. Office of Government Ethics; 5 C.F.R. part 2634   Form Approved: OMB No. (3209-0001) (January 2018)

Executive Branch Personnel
Public Financial Disclosure Report (OGE Form 278e)
Filer's Information
Muzinich, Justin
Deputy Secretary Of The Treasury, Department of the Treasury
Report Year: 2019
Other Federal Government Positions Held During the Preceding 12 Months:
Counselor to the Secretary (2/2017 - 12/2018)

Electronic Signature - I certify that the statements I have made in this form are true, complete and correct to the best of my knowledge.
/s/ Muzinich, Justin [electronically signed on 06/29/2019 by Muzinich, Justin in Integrity.gov] - Filer received a 47 day filing extension.

Agency Ethics Official's Opinion - On the basis of information contained in this report, I conclude that the filer is in compliance with applicable laws and regulations
(subject to any comments below).
/s/ Sonfield, Brian, Certifying Official [electronically signed on 10/18/2019 by Sonfield, Brian in Integrity.gov]

Other review conducted by
/s/ Bunaugh, Tremayne, Ethics Official [electronically signed on 10/17/2019 by Bunaugh, Tremayne in Integrity.gov]

U.S. Office of Government Ethics Certification

Muzinich, Justin - Page 1

 Data Revised 10/17/2019
Data Revised 10/10/2019
Data Revised 10/09/2019
Data Revised 10/04/2019

Muzinich, Justin - Page 2

 1. Filer's Positions Held Outside United States Government
#

ORGANIZATION NAME

CITY, STATE

ORGANIZATION
TYPE

POSITION HELD

FROM

TO

1

New York Presbyterian Hospital

New York, New
York

Hospital

Trustee

11/2006

12/2018

2

Family Trust #3

See Endnote

New York, New
York

Trust

Trustee

1/2012

Present

3

The Buckley School

See Endnote

New York, New
York

K-9 Day School

Director

11/2017

12/2018

EIF

VALUE

INCOME TYPE

INCOME
AMOUNT

2. Filer's Employment Assets & Income and Retirement Accounts
#

DESCRIPTION

1

IRA #1

1.1

Fidelity Adv Growth & Income-CL T

Yes

$1,001 - $15,000

$201 - $1,000

1.2

Fidelity Adv Stock Selector Mid Cap - CL T

Yes

$1,001 - $15,000

$201 - $1,000

2

401(k)

2.1

Franklin Income Adv

Yes

$100,001 $250,000

$1,001 - $2,500

3

IRA #2

3.1

U.S. bank account (cash)

N/A

$100,001 $250,000

Interest

None (or less
than $201)

3.2

Equinix, Inc. (EQIX)

N/A

None (or less
than $1,001)

Capital Gains
Dividends

$50,001 $100,000

3.3

PowerShares QQQ Trust, Series 1 (QQQ)

Yes

$50,001 $100,000

$201 - $1,000

Muzinich, Justin - Page 3

 #

DESCRIPTION

EIF

VALUE

3.4

SPDR S&P 500 ETF Trust (SPY)

Yes

$50,001 $100,000

INCOME TYPE

INCOME
AMOUNT
$201 - $1,000

3. Filer's Employment Agreements and Arrangements
#

EMPLOYER OR PARTY

CITY, STATE

STATUS AND TERMS

DATE

1

Muzinich & Co.

New York, New
York

I will continue to participate in Muzinich & Co.'s 401(k)
plan. No contributions will be made by my former
employer.

1/2004

4. Filer's Sources of Compensation Exceeding $5,000 in a Year
(N/A) - Not required for this type of report

5. Spouse's Employment Assets & Income and Retirement Accounts
#

DESCRIPTION

EIF

1

Columbia University

N/A

VALUE

INCOME TYPE

INCOME
AMOUNT

Wages

6. Other Assets and Income
#

DESCRIPTION

EIF

VALUE

INCOME TYPE

INCOME
AMOUNT

1

U.S. bank account #1

N/A

$250,001 $500,000

Interest

$201 - $1,000

Muzinich, Justin - Page 4

 #

DESCRIPTION

EIF

VALUE

INCOME TYPE

INCOME
AMOUNT

2

U.S. bank account #2

N/A

$100,001 $250,000

Interest

None (or less
than $201)

3

U.S. bank account #3

N/A

$100,001 $250,000

Interest

$5,001 - $15,000

4

U.S. bank account #4

N/A

$100,001 $250,000

Interest

None (or less
than $201)

5

U.S. bank account #5

N/A

$1,001 - $15,000

Interest

None (or less
than $201)

6

U.S. brokerage account #1

No

6.1

U.S. brokerage account (cash)

N/A

$1,000,001 $5,000,000

Interest

$5,001 - $15,000

6.2

Alphabet Inc Class C (GOOG)

N/A

None (or less
than $1,001)

Capital Gains

$100,001 $1,000,000

6.3

Alphabet Inc Class A (GOOGL)

N/A

None (or less
than $1,001)

Capital Gains

$100,001 $1,000,000

6.4

PowerShares QQQ Trust, Series 1 (QQQ)

Yes

$15,001 $50,000

$201 - $1,000

6.5

SPDR S&P 500 ETF Trust (SPY)

Yes

$15,001 $50,000

$201 - $1,000

7

U.S. brokerage account #2

No

7.1

Cash Account

N/A

8

Family Trust #3

N/A

8.1

U.S. bank account (cash)

8.2

Receivable from Family

None (or less
than $201)
$5,000,001 $25,000,000

Interest

None (or less
than $201)

N/A

None (or less
than $1,001)

Interest

None (or less
than $201)

N/A

Over
$50,000,000

Interest

$1,000,001 $5,000,000

Muzinich, Justin - Page 5

 #

DESCRIPTION

EIF

9

Line Intentionally Left Blank

10

Austin Family Partners

See Endnote

No

10.1

Tiger Eye Partners, LP - Receivable

See Endnote

Yes

None (or less
than $1,001)

10.2

Azaya Therapeutics - Nanoparticle
Therapeutics

See Endnote

N/A

$15,001 $50,000

10.3

Halifax Investors II L.P.

Yes

$15,001 $50,000

10.4

Jonah Energy LLC (Oil & gas exploration and
production in Wyoming and Colorado)

N/A

$500,001 $1,000,000

Distributions

$60,594

10.5

RLH Investors II, LP

No

$15,001 $50,000

Dividends
Capital Gains
Interest

$100,001 $1,000,000

10.5.1

Total Woman Holdings Inc

See Endnote

N/A

10.5.2

Avella Specialty Pharmacy

See Endnote

N/A

10.5.3

RLH Bluewolf Holding, LLC

See Endnote

N/A

10.6

RLH Investors III, LP

$500,001 $1,000,000

Dividends
Capital Gains
Interest

$15,001 $50,000

10.6.1

DCRX Infusion

See Endnote

N/A

10.6.2

Bluewolf Group

See Endnote

N/A

10.6.3

RMG Group

See Endnote

N/A

10.6.4

Sitworx

See Endnote

N/A

10.6.5

The Chartis Group

See Endnote

N/A

10.7

Las Vivoritas Ltd (South Texas Ranch - Jim
Hogg County)

See Endnote

N/A

No

VALUE

Over $1,000,000

INCOME TYPE

INCOME
AMOUNT

Distributions

$50,000
$5,001 - $15,000

Dividends
Capital Gains
Interest

None (or less
than $201)
None (or less
than $201)

None (or less
than $201)

Muzinich, Justin - Page 6

 #

DESCRIPTION

EIF

VALUE

10.8

U.S. bank account #1 (cash)

N/A

None (or less
than $1,001)

10.9

Schwab Treasury Obligation Money Fund

N/A

$100,001 $250,000

11

EDA Investments

11.1

Altria Group Inc.

N/A

11.2

Anheuser-Busch InBev NV

11.3

INCOME TYPE

INCOME
AMOUNT
None (or less
than $201)

Interest

$5,001 - $15,000

Distribution

$260,000

None (or less
than $1,001)

Dividends
Capital Gains

$15,001 $50,000

N/A

None (or less
than $1,001)

Capital Gains
Dividends

$15,001 $50,000

British American Tobacco PLC

N/A

None (or less
than $1,001)

Capital Gains
Dividends

$5,001 - $15,000

11.4

Brown Forman Corp CL A

N/A

None (or less
than $1,001)

Capital Gains
Dividends

$15,001 $50,000

11.5

Brown Forman Corp CL B

N/A

None (or less
than $1,001)

Dividends
Capital Gains

$5,001 - $15,000

11.6

Cie Financiere Richemont A

N/A

None (or less
than $1,001)

Capital Gains
Dividends

$15,001 $50,000

11.7

Comcast Corp New CL A

N/A

None (or less
than $1,001)

Capital Gains
Dividends

$15,001 $50,000

11.8

Diageo PLC

N/A

None (or less
than $1,001)

Capital Gains

$5,001 - $15,000

11.9

Heineken Holding NC

N/A

None (or less
than $1,001)

Dividends
Capital Gains

$50,001 $100,000

11.10

JCDecaux SA

N/A

None (or less
than $1,001)

Dividends
Capital Gains

$1,001 - $2,500

11.11

Martin Marietta Matls Com

N/A

None (or less
than $1,001)

Dividends
Capital Gains

$15,001 $50,000

11.12

Nestle SA Sponsored ADR

N/A

None (or less
than $1,001)

Dividends
Capital Gains

$15,001 $50,000

See Endnote

Muzinich, Justin - Page 7

 #

DESCRIPTION

EIF

VALUE

INCOME TYPE

INCOME
AMOUNT

11.13

Pernod Ricard SA

N/A

None (or less
than $1,001)

Dividends
Capital Gains

$15,001 $50,000

11.14

Philip Morris Intl Inc.

N/A

None (or less
than $1,001)

Dividends
Capital Gains

$100,001 $1,000,000

11.15

Swatch Group AG

N/A

None (or less
than $1,001)

Dividends
Capital Gains

$5,001 - $15,000

11.16

Unilever NV NY Shs New

N/A

None (or less
than $1,001)

Dividends
Capital Gains

$50,001 $100,000

11.17

Anchor Bolt Fund, LP

See Endnote

Yes

$250,001 $500,000

None (or less
than $201)

11.18

Senator Global Opportunity Fund, LP

See Endnote

Yes

$500,001 $1,000,000

None (or less
than $201)

11.19

Alphabet Inc CL C

N/A

None (or less
than $1,001)

Dividends
Capital Gains

$100,001 $1,000,000

11.20

Apple Inc

N/A

None (or less
than $1,001)

Capital Gains
Dividends

$100,001 $1,000,000

11.21

Bristol Myers Squibb Com

N/A

None (or less
than $1,001)

Dividends
Capital Gains

$15,001 $50,000

11.22

Coca Cola

N/A

None (or less
than $1,001)

Dividends
Capital Gains

$5,001 - $15,000

11.23

Intel Corp

N/A

None (or less
than $1,001)

Capital Gains
Dividends

$100,001 $1,000,000

11.24

Johnson & Johnson

N/A

None (or less
than $1,001)

Capital Gains
Dividends

$50,001 $100,000

11.25

Kinder Morgan Inc.

N/A

None (or less
than $1,001)

Dividends
Capital Gains

None (or less
than $201)

11.26

Merck & Co. Inc.

N/A

None (or less
than $1,001)

None (or less
than $201)

Muzinich, Justin - Page 8

 #

DESCRIPTION

EIF

VALUE

INCOME TYPE

INCOME
AMOUNT

11.27

Pepsico Inc.

N/A

None (or less
than $1,001)

Capital Gains
Dividends

$15,001 $50,000

11.28

RSP Permian Inc.

N/A

None (or less
than $1,001)

Interest
Capital Gains
Dividends

$5,001 - $15,000

11.29

Shake Shack Inc. - Class A

N/A

None (or less
than $1,001)

Dividends
Capital Gains

$1,001 - $2,500

11.30

IP San Antonio Station, LLC (multi family real
estate in San Antonio, TX)

N/A

$50,001 $100,000

Distributions

$2,500

11.31

The Garden of the Gods LLC - Residential
Real Estate Development - Colorado Springs,
CO

N/A

$250,001 $500,000

11.32

Walmart Stores, Inc.

N/A

None (or less
than $1,001)

11.33

This line is intentionally left blank.

11.34

Charles Schwab Money Market Fund

Yes

$5,000,001 $25,000,000

11.35

Charles Schwab Sweep Account (cash)

N/A

$50,001 $100,000

12

Line Intentionally Left Blank

13

UTMA #1

13.1

SPDR S&P 500 (SPY)

Yes

$15,001 $50,000

13.2

U.S. bank account (cash)

N/A

$15,001 $50,000

Interest

$201 - $1,000

14

UTMA #2

14.1

U.S. bank account (cash)

N/A

$1,001 - $15,000

Interest

None (or less
than $201)

None (or less
than $201)
Dividends
Capital Gains

$5,001 - $15,000

$15,001 $50,000
Interest

$201 - $1,000

$201 - $1,000

Muzinich, Justin - Page 9

 #

DESCRIPTION

EIF

VALUE

INCOME TYPE

INCOME
AMOUNT

15

Lewis and Clark LLC

15.1

U.S. bank account (cash)

N/A

$50,001 $100,000

Interest

None (or less
than $201)

16

Austin Trust #1

See Endnote

No

16.1

Austin Family Partners

See Endnote

No

Distributions

$9,147

16.2

EDA Investments

See Endnote

No

Distributions

$47,565

17

Austin Trust #2

See Endnote

No

17.1

Austin Family Partners

See Endnote

No

Distributions

$16,581

17.2

EDA Investments

See Endnote

No

Distribution

$86,218

7. Transactions
#

DESCRIPTION

TYPE

DATE

AMOUNT

1

Anheuser-Busch InBev NV

Purchase

01/05/2018

$1,001 - $15,000

2

Alphabet Inc Class C (GOOG)

Sale

02/05/2018

$250,001 $500,000

3

Alphabet Inc Class A (GOOGL)

Sale

02/05/2018

$250,001 $500,000

4

Equinix (EQIX)

Sale

02/05/2018

$100,001 $250,000

5

Alphabet Inc Cl C

Sale

2/21/18

$250,001 $500,000

6

Coca Cola Co

Sale

2/2/18

$15,001 $50,000

7

Apple Inc.

Sale

2/21/18

$500,001 $1,000,000

Muzinich, Justin - Page 10

 #

DESCRIPTION

TYPE

DATE

AMOUNT

8

Bristol Myers Squibb Com

Sale

2/21/18

$15,001 $50,000

9

Altria Group Inc

Sale

2/21/18

$15,001 $50,000

10

Comcast Corp New Cl A

Sale

2/21/18

$15,001 $50,000

11

Brown Forman Corp Cl A

Sale

2/21/18

$15,001 $50,000

12

Johnson & Johnson

Sale

2/21/18

$250,001 $500,000

13

Martin Marietta Matls Com

Sale

2/21/18

$15,001 $50,000

14

Merck & Co., Inc.

Sale

2/21/18

$100,001 $250,000

15

Intel Corp

Sale

2/21/18

$100,001 $250,000

16

Nestle SA Sponsored ADR

Sale

2/21/18

$250,001 $500,000

17

Kinder Morgan Inc

Sale

2/21/18

$250,001 $500,000

18

Pepsico Inc

Sale

2/21/18

$100,001 $250,000

19

Philip Morris Intl Inc

Sale

2/21/18

$1,000,001 $5,000,000

20

Shake Shack Inc - Class A

Sale

2/21/18

$15,001 $50,000

21

Wal Mart Stores Inc

Sale

2/21/18

$100,001 $250,000

22

Unilever NV NY Shs New

Sale

2/21/18

$100,001 $250,000

Muzinich, Justin - Page 11

 #

DESCRIPTION

TYPE

DATE

AMOUNT

23

RSP Permian Inc

Sale

2/21/18

$50,001 $100,000

24

Anheuser Busch Inbev Sa Nv Shs

Sale

2/27/18

$100,001 $250,000

25

British American Tobacco Plc Ord

Sale

2/27/18

$15,001 $50,000

26

Diageo PLC

Sale

2/27/18

$15,001 $50,000

27

Cie Financiere Richemont SA

Sale

2/27/18

$100,001 $250,000

28

Heineken Holding NV

Sale

2/27/18

$100,001 $250,000

29

JCDecaux SA

Sale

2/27/18

$15,001 $50,000

30

Swatch Group AG

Sale

2/27/18

$50,001 $100,000

31

Pernod Ricard SA

Sale

3/02/18

$100,001 $250,000

32

Brown Forman Corp Cl B

Sale

02/21/18

$1,001 - $15,000

8. Liabilities
#

CREDITOR NAME

TYPE

AMOUNT

YEAR
INCURRED

RATE

TERM

1

Muzinich & Co.

Note Payable

$1,000,001 $5,000,000

2013

1%

9 years

2

Bank of America

Credit Card

$15,001 $50,000

2018

14.24%

Revolving

Muzinich, Justin - Page 12

 9. Gifts and Travel Reimbursements
None

Endnotes
PART

#

ENDNOTE

1.

2

Start date is approximate.

1.

3

Start date is approximate.

6.

10

This entity is owned by Austin Trust #1 (line 16), Austin Trust #2 (line 17) and the filer's spouse
individually. Distributions from Austin Family Partners encompass the income listed on line 10.1
through 10.9.

6.

10.1

The fund was originally an EIF, and this is reflected on the form. This investment has been sold and
there was only a holdback payment remaining.

6.

10.2

Income not available

6.

10.5.1

Los Angeles, Calif. women's gym and spa facilities

6.

10.5.2

Phoenix, Ariz. specialty pharmacy company

6.

10.5.3

Holds an interest in Bluewolf Group, a New York software and IT consulting business

6.

10.6.1

Sunrise, Fla. intravenous nutrition company

6.

10.6.2

New York, N.Y. software and IT consulting business

6.

10.6.3

New York, N.Y. digital advertising company

6.

10.6.4

Reston, Va. digital marketing software company

6.

10.6.5

Chicago, Ill. provider of services to hospitals

Muzinich, Justin - Page 13

 PART

#

ENDNOTE

6.

10.7

Las Vivoritas Ltd. is a ranch located in South Texas use primarily for hunting. It receives a nominal
amount for cattle and leases to hunters during hunting season.

6.

11

This entity is owned by Austin Trust #1 (line 16), Austin Trust #2 (line 17) and the filer's spouse
individually. Distributions from EDA Investments encompass the income listed on line 11.1 through
11.35.

6.

11.17

Income data not available

6.

11.18

Income data not available

6.

16

Distributions to Austin Family Partners and EDA Investments and then to Austin Trust #1.

6.

16.1

All income and value reflected in lines 10.1 through 10.9.

6.

16.2

All income and value reflected in lines 11.1 through 11.35.

6.

17

Distributions to Austin Family Partners and EDA Investments and then to Austin Trust #2.

6.

17.1

All income and value reflected in lines 10.1 through 10.9.

6.

17.2

All income and value reflected in lines 11.1 through 11.35.

Muzinich, Justin - Page 14

 Summary of Contents
1. Filer's Positions Held Outside United States Government
Part 1 discloses positions that the filer held at any time during the reporting period (excluding positions with the United States Government). Positions are reportable
even if the filer did not receive compensation.
This section does not include the following: (1) positions with religious, social, fraternal, or political organizations; (2) positions solely of an honorary nature; (3) positions
held as part of the filer's official duties with the United States Government; (4) mere membership in an organization; and (5) passive investment interests as a limited
partner or non-managing member of a limited liability company.
2. Filer's Employment Assets & Income and Retirement Accounts
Part 2 discloses the following:
●

●

Sources of earned and other non-investment income of the filer totaling more than $200 during the reporting period (e.g., salary, fees, partnership share,
honoraria, scholarships, and prizes)
Assets related to the filer's business, employment, or other income-generating activities that (1) ended the reporting period with a value greater than $1,000 or (2)
produced more than $200 in income during the reporting period (e.g., equity in business or partnership, stock options, retirement plans/accounts and their
underlying holdings as appropriate, deferred compensation, and intellectual property, such as book deals and patents)

This section does not include assets or income from United States Government employment or assets that were acquired separately from the filer's business,
employment, or other income-generating activities (e.g., assets purchased through a brokerage account). Note: The type of income is not required if the amount of
income is $0 - $200 or if the asset qualifies as an excepted investment fund (EIF).
3. Filer's Employment Agreements and Arrangements
Part 3 discloses agreements or arrangements that the filer had during the reporting period with an employer or former employer (except the United States
Government), such as the following:
●
●
●
●
●

Future employment
Leave of absence
Continuing payments from an employer, including severance and payments not yet received for previous work (excluding ordinary salary from a current employer)
Continuing participation in an employee welfare, retirement, or other benefit plan, such as pensions or a deferred compensation plan
Retention or disposition of employer-awarded equity, sharing in profits or carried interests (e.g., vested and unvested stock options, restricted stock, future share of
a company's profits, etc.)

Muzinich, Justin - Page 15

 4. Filer's Sources of Compensation Exceeding $5,000 in a Year
Part 4 discloses sources (except the United States Government) that paid more than $5,000 in a calendar year for the filer's services during any year of the reporting
period.
The filer discloses payments both from employers and from any clients to whom the filer personally provided services. The filer discloses a source even if the source
made its payment to the filer's employer and not to the filer. The filer does not disclose a client's payment to the filer's employer if the filer did not provide the services
for which the client is paying.
5. Spouse's Employment Assets & Income and Retirement Accounts
Part 5 discloses the following:
●

●
●

Sources of earned income (excluding honoraria) for the filer's spouse totaling more than $1,000 during the reporting period (e.g., salary, consulting fees, and
partnership share)
Sources of honoraria for the filer's spouse greater than $200 during the reporting period
Assets related to the filer's spouse's employment, business activities, other income-generating activities that (1) ended the reporting period with a value greater
than $1,000 or (2) produced more than $200 in income during the reporting period (e.g., equity in business or partnership, stock options, retirement plans/accounts
and their underlying holdings as appropriate, deferred compensation, and intellectual property, such as book deals and patents)

This section does not include assets or income from United States Government employment or assets that were acquired separately from the filer's spouse's business,
employment, or other income-generating activities (e.g., assets purchased through a brokerage account). Note: The type of income is not required if the amount of
income is $0 - $200 or if the asset qualifies as an excepted investment fund (EIF). Amounts of income are not required for a spouse's earned income (excluding
honoraria).
6. Other Assets and Income
Part 6 discloses each asset, not already reported, that (1) ended the reporting period with a value greater than $1,000 or (2) produced more than $200 in investment
income during the reporting period. For purposes of the value and income thresholds, the filer aggregates the filer's interests with those of the filer's spouse and
dependent children.
This section does not include the following types of assets: (1) a personal residence (unless it was rented out during the reporting period); (2) income or retirement
benefits associated with United States Government employment (e.g., Thrift Savings Plan); and (3) cash accounts (e.g., checking, savings, money market accounts) at a
single financial institution with a value of $5,000 or less (unless more than $200 of income was produced). Additional exceptions apply. Note: The type of income is not
required if the amount of income is $0 - $200 or if the asset qualifies as an excepted investment fund (EIF).
7. Transactions

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 Part 7 discloses purchases, sales, or exchanges of real property or securities in excess of $1,000 made on behalf of the filer, the filer's spouse or dependent child during
reporting period.
This section does not include transactions that concern the following: (1) a personal residence, unless rented out; (2) cash accounts (e.g., checking, savings, CDs, money
market accounts) and money market mutual funds; (3) Treasury bills, bonds, and notes; and (4) holdings within a federal Thrift Savings Plan account. Additional
exceptions apply.
8. Liabilities
Part 8 discloses liabilities over $10,000 that the filer, the filer's spouse or dependent child owed at any time during the reporting period.
This section does not include the following types of liabilities: (1) mortgages on a personal residence, unless rented out (limitations apply for PAS filers); (2) loans
secured by a personal motor vehicle, household furniture, or appliances, unless the loan exceeds the item's purchase price; and (3) revolving charge accounts, such as
credit card balances, if the outstanding liability did not exceed $10,000 at the end of the reporting period. Additional exceptions apply.
9. Gifts and Travel Reimbursements
This section discloses:
●
●

Gifts totaling more than $390 that the filer, the filer's spouse, and dependent children received from any one source during the reporting period.
Travel reimbursements totaling more than $390 that the filer, the filer's spouse, and dependent children received from any one source during the reporting period.

For purposes of this section, the filer need not aggregate any gift or travel reimbursement with a value of $156 or less. Regardless of the value, this section does not
include the following items: (1) anything received from relatives; (2) anything received from the United States Government or from the District of Columbia, state, or
local governments; (3) bequests and other forms of inheritance; (4) gifts and travel reimbursements given to the filer's agency in connection with the filer's official travel;
(5) gifts of hospitality (food, lodging, entertainment) at the donor's residence or personal premises; and (6) anything received by the filer's spouse or dependent children
totally independent of their relationship to the filer. Additional exceptions apply.

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 Privacy Act Statement
Title I of the Ethics in Government Act of 1978, as amended (the Act), 5 U.S.C. app. § 101 et seq., as amended by the Stop Trading on Congressional Knowledge Act of
2012 (Pub. L. 112-105) (STOCK Act), and 5 C.F.R. Part 2634 of the U. S. Office of Government Ethics regulations require the reporting of this information. The primary use
of the information on this report is for review by Government officials to determine compliance with applicable Federal laws and regulations. This report may also be
disclosed upon request to any requesting person in accordance with sections 105 and 402(b)(1) of the Act or as otherwise authorized by law. You may inspect
applications for public access of your own form upon request. Additional disclosures of the information on this report may be made: (1) to any requesting person,
subject to the limitation contained in section 208(d)(1) of title 18, any determination granting an exemption pursuant to sections 208(b)(1) and 208(b)(3) of title 18; (2) to
a Federal, State, or local law enforcement agency if the disclosing agency becomes aware of violations or potential violations of law or regulation; (3) to another Federal
agency, court or party in a court or Federal administrative proceeding when 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 investigation or determination; (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; (7) to the Department of Justice or in certain legal proceedings when the disclosing agency, an 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; (8) to reviewing officials in a new
office, department or agency when an employee transfers or is detailed from one covered position to another; (9) 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; (10) to contractors and other non-Government employees working on a
contract, service or assignment for the Federal Government when necessary to accomplish a function related to an OGE Government-wide system of records; and (11)
on the OGE Website and to any person, department or agency, any written ethics agreement filed with OGE by an individual nominated by the President to a position
requiring Senate confirmation. See also the OGE/GOVT-1 executive branch-wide Privacy Act system of records.
Public Burden Information
This collection of information is estimated to take an average of three hours per response, including time for reviewing the instructions, gathering the data needed, and
completing the form. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this
burden, to the Program Counsel, U.S. Office of Government Ethics (OGE), Suite 500, 1201 New York Avenue, NW., Washington, DC 20005-3917.
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, 3209-0001, is displayed here and at the top of the first page of this OGE Form 278e).

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