Form OSM23 "State Employee Statement of Employment and Financial Interest"

What Is Form OSM23?

This is a legal form that was released by the U.S. Department of the Interior - Office of Surface Mining, Reclamation and Enforcement on August 1, 1989 and used country-wide. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on August 1, 1989;
  • The latest available edition released by the U.S. Department of the Interior - Office of Surface Mining, Reclamation and Enforcement;
  • Easy to use and ready to print;
  • Yours to fill out and keep for your records;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form OSM23 by clicking the link below or browse more documents and templates provided by the U.S. Department of the Interior - Office of Surface Mining, Reclamation and Enforcement.

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UNITED STATES DEPARTMENT OF THE INTERIOR
FORM OSM 23 (8/89)
Approved by OMB
Office of Surface Mining Reclamation and Enforcement
CN 1029-0067
State Employee Statement of Employment and Financial Interest
Expires: 8/31/2023
1. Name (Last, First, Initial)
2. Title of Position
3. Date of Appointment (in present position)
4. Organizational Unit
5. Duty Station (Office location)
6. Telephone No.
7. Calendar Year (previous)
General Instructions. Report all interests held during the previous calendar year (indicate which ones are no longer held), use attachments as necessary.
In the event that any of the required information is not known to you, but is known to another person (e.g., trustee, accountant, relative), request that
the other person submit the information on your behalf. Provide the name and address of the other person, and include the date you requested the
information to be supplied. Briefly explain the situation and the information requested. Codes: (E) for Employee, (J) for Joint ownership with
spouse, minor child or other relatives, (S) for Spouse, (C) for minor child or (R) for other Relatives who are full-time residents in your immediate
household.
Part I. Employment and Securities. List the names of business entities, non-profit organizations, educational and other institutions in which you,
your spouse, minor child or other relatives who are full-time residents of your immediate household have a financial interest, including but not limited
to: (1) an interest as an employee, officer, owner, director, trustee, partner or consultant; (2) a continuing financial interest through a pension or
retirement plan, individual retirement account, shared income, or other arrangement as a result of any current or prior employment; (3) any financial
interest through the ownership of stock, bonds, securities or other arrangement including trusts. You may exclude: (1) positions with charitable,
religious, fraternal, political organizations or any similar organization and those solely of an honorary nature; (2) holdings in widely held diversified
mutual funds, investment clubs or regulated investment companies not specializing in underground and surface coal mining operations; (3)
employment, pension or retirement plans with the U.S. or State Governments; and (4) retirement plans with a guaranteed income. A guaranteed income
is one which is unlikely to be changed as a result of actions taken by the State regulatory authority.
NONE
Code J, S,
Name and Address of Organization
Description of Interest
Nature of Employment and Financial
C or R
(e.g., employment, stock)
Interest (e.g., salary, dividends)
Part II. REAL PROPERTY. List property in which you, your spouse, minor child or other relatives who are full-time residents of your
immediate household have an interest. Exclude your personal residence. Personal residence means any real property used exclusively as a private
dwelling.
NONE
Code J, S,
Nature of Interests (e.g., ownership,
Description of Interest
Location of Interest
C or R
lease, royalty, mineral rights)
(e.g., employment, stock)
(county and state)
Part III. CREDITORS. List debts owed to business entities and non-profit organizations to whom you, your spouse, minor child or other relatives
who are full-time residents of your immediate household are indebted. Exclude debts owed to financial institutions (e.g., banks, credit unions), credit
cards, and those for ordinary household and living expenses.
NONE
Code J, S,
Nature of Interests (e.g., ownership,
Description of Interest
Location of Interest
C or R
lease, royalty, mineral rights)
(e.g., employment, stock)
(county and state)
Part IV. EMPLOYEE CERTIFICATION. To the best of my knowledge, none of the employment and financial interests listed represents an interest
in an underground or surface coal mining operation except as follows:
NONE
Code J, S,
Nature of Interests (e.g., employment, mineral rights, stock, undeveloped land)
C or R
I certify that the statements I have made are true, correct, and complete to the best of my knowledge.
Signature of Employee
Date
UNITED STATES DEPARTMENT OF THE INTERIOR
FORM OSM 23 (8/89)
Approved by OMB
Office of Surface Mining Reclamation and Enforcement
CN 1029-0067
State Employee Statement of Employment and Financial Interest
Expires: 8/31/2023
1. Name (Last, First, Initial)
2. Title of Position
3. Date of Appointment (in present position)
4. Organizational Unit
5. Duty Station (Office location)
6. Telephone No.
7. Calendar Year (previous)
General Instructions. Report all interests held during the previous calendar year (indicate which ones are no longer held), use attachments as necessary.
In the event that any of the required information is not known to you, but is known to another person (e.g., trustee, accountant, relative), request that
the other person submit the information on your behalf. Provide the name and address of the other person, and include the date you requested the
information to be supplied. Briefly explain the situation and the information requested. Codes: (E) for Employee, (J) for Joint ownership with
spouse, minor child or other relatives, (S) for Spouse, (C) for minor child or (R) for other Relatives who are full-time residents in your immediate
household.
Part I. Employment and Securities. List the names of business entities, non-profit organizations, educational and other institutions in which you,
your spouse, minor child or other relatives who are full-time residents of your immediate household have a financial interest, including but not limited
to: (1) an interest as an employee, officer, owner, director, trustee, partner or consultant; (2) a continuing financial interest through a pension or
retirement plan, individual retirement account, shared income, or other arrangement as a result of any current or prior employment; (3) any financial
interest through the ownership of stock, bonds, securities or other arrangement including trusts. You may exclude: (1) positions with charitable,
religious, fraternal, political organizations or any similar organization and those solely of an honorary nature; (2) holdings in widely held diversified
mutual funds, investment clubs or regulated investment companies not specializing in underground and surface coal mining operations; (3)
employment, pension or retirement plans with the U.S. or State Governments; and (4) retirement plans with a guaranteed income. A guaranteed income
is one which is unlikely to be changed as a result of actions taken by the State regulatory authority.
NONE
Code J, S,
Name and Address of Organization
Description of Interest
Nature of Employment and Financial
C or R
(e.g., employment, stock)
Interest (e.g., salary, dividends)
Part II. REAL PROPERTY. List property in which you, your spouse, minor child or other relatives who are full-time residents of your
immediate household have an interest. Exclude your personal residence. Personal residence means any real property used exclusively as a private
dwelling.
NONE
Code J, S,
Nature of Interests (e.g., ownership,
Description of Interest
Location of Interest
C or R
lease, royalty, mineral rights)
(e.g., employment, stock)
(county and state)
Part III. CREDITORS. List debts owed to business entities and non-profit organizations to whom you, your spouse, minor child or other relatives
who are full-time residents of your immediate household are indebted. Exclude debts owed to financial institutions (e.g., banks, credit unions), credit
cards, and those for ordinary household and living expenses.
NONE
Code J, S,
Nature of Interests (e.g., ownership,
Description of Interest
Location of Interest
C or R
lease, royalty, mineral rights)
(e.g., employment, stock)
(county and state)
Part IV. EMPLOYEE CERTIFICATION. To the best of my knowledge, none of the employment and financial interests listed represents an interest
in an underground or surface coal mining operation except as follows:
NONE
Code J, S,
Nature of Interests (e.g., employment, mineral rights, stock, undeveloped land)
C or R
I certify that the statements I have made are true, correct, and complete to the best of my knowledge.
Signature of Employee
Date
Part V. REVIEWERS CERTIFICATION. Review completed and prohibited interests, if any, have been resolved. Reviewer’s comments, if any,
show the basis for the certification:
Signature of Reviewer
Date
PRIVACY AND PAPERWORK REDUCTION ACT NOTICES
Section 517(g) of Public Law 95-87, the Surface Mining Control and Reclamation Act, and 30 CFR 705, constitute the authority for collecting the
personal data on this statement of employment and financial interests. This data must be furnished. Knowing failure to file or report information
required may subject you to disciplinary action by your employing agency or other appropriate authority. Knowing failure to file or report information
required may also subject you to criminal prosecution leading to a fine of not more than $2,500 or imprisonment for not more than one year or both.
The information gathered from the statement will be used to determine whether there are any direct or indirect financial interests in violation of Section
517(g) of Public Law 95-87.
Maintenance of the statement by the State regulatory authority is subject to State law. Pursuant to 30 CFR 705 the statement may be inspected by or
provided to representatives of the U.S. Department of the Interior.
If the statement is provided to the U.S. Department of the Interior, the statement will be subject to the requirements of Federal law, including the
Privacy Act of 1974, 5 U.S.C. 552a. The U.S. Department of the Interior may make routine disclosures: (1) from the records of an individual in
response to an inquiry from a Congressional office made at the request of that individual; (2) to the U.S. Department of Justice when related to
litigation or anticipated litigation involving the records or the subject matter of the records; and (3) to appropriate State and Federal law enforcement
agencies. Systems of Records Notices (SORN) for statements of employment and financial interest is found at https://www.doi.gov/privacy/
osm_notices.
Public reporting burden for this form is estimated to average 5 minutes per response, including time for reviewing instructions, gathering and
maintaining data, and completing and reviewing the form. You are not required to respond to this collection of information unless it displays a
currently valid OMB control number. Direct comments regarding the burden estimate or any other aspect of this form to the Information Collection
Clearance Officer, Office of Surface Mining Reclamation and Enforcement, Room 4556 MIB, 1849 C Street., NW, Washington, D.C., 20240.
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