Document b5MKzqGLk89G822R69vBopD2y

UNITED STATES SENATE COMMITTEE ON ENVIRONMENT AND PUBLIC WORKS STATEMENT FOR COMPLETION BY PRESIDENTIAL NOMINEES UNITED STATES SENATE COMMITTEE ON ENVIRONMENT AND PUBLIC WORKS ROOM 410 DIRKSEN SENATE OFFICE BUILDING WASHINGTON, DC 20510 INFORMATION REQUESTED OF PRESIDENTIAL NOMINEES In order to assist the Committee in its consideration of nominations, each nominee is requested to complete the attached Statement for completion by Presidential Nominees. The Statement is intended to be publicly available. In the event that a nominee asks that a specific answer be kept confidential, he or she should notify the Chairman and Ranking Member. The original and forty (40) copies of the requested information should be made available to the Honorable John Barrasso, Chairman, Committee on Environment and Public Works, U S. Senate, Washington, DC 20510 (Attn: Matt Leggett) as soon as possible. Name of Nominee: Position to which nominated: Date of Nomination: Business Name: Business Address: Sierra Club v. EPA 18cv3472 NDCA Tier 1 ED 002061 00170008-00001 UNITED STATES SENATE COMMITTEE ON ENVIRONMENT AND PUBLIC WORKS STATEMENT FOR COMPLETION BY PRESIDENTIAL NOMINEES City, State & Zip: Business E-mail: Business Phone: Full Legal Name: Date of birth: State of residency: Education: Institution Dates Attended Degrees Received Dates of Degrees Sierra Club v. EPA 18cv3472 NDCA Tier 1 ED 002061 00170008-00002 UNITED STATES SENATE COMMITTEE ON ENVIRONMENT AND PUBLIC WORKS STATEMENT FOR COMPLETION BY PRESIDENTIAL NOMINEES Employment Record List all positions held since college, including the title and description of job, name of employer, location, and dates. If you were terminated involuntarily from any position(s), please note the circumstances. Attach additional pages if necessary. Position Title Employer Address Dates Terminate d (Y/N) Honors and Awards: List significant scholarships, fellowships, honorary degrees, military medals, honorary society memberships, and any other special recognition for outstanding service or achievement. Attach additional pages if necessary. Date Honor/Award Sierra Club v. EPA 18cv3472 NDCA Tier 1 ED 002061 00170008-00003 UNITED STATES SENATE COMMITTEE ON ENVIRONMENT AND PUBLIC WORKS STATEMENT FOR COMPLETION BY PRESIDENTIAL NOMINEES Memberships: List significant memberships and offices held in professional, fraternal, business, scholarly, civic, _____ charitable and other organizations. Attach additional pages if necessary.__________ Organization Office held (if any) Dates Qualifications: State fully your qualifications to serve in the position to which you have been nominated. Future employment relationships: 1. Indicate whether you will sever all connections with your present employer, business firm, association or organization if you are confirmed by the Senate. ____Yes. ____No. If not, please explain: Sierra Club v. EPA 18cv3472 NDCA Tier 1 ED 002061 00170008-00004 UNITED STATES SENATE COMMITTEE ON ENVIRONMENT AND PUBLIC WORKS STATEMENT FOR COMPLETION BY PRESIDENTIAL NOMINEES 2. As far as can be foreseen, state whether you have any plans after completing government service to resume employment, affiliation or practice with your current or any previous employer, business firm, association or organization. ____Yes. If so, please explain: No. 3. Has anybody made a commitment to you for a job after you leave government? Yes. If so, please explain: ____No. 4. (a) If you have been appointed for a fixed term, do you expect to serve the full term? ____Yes. ____No. (b) If you have been appointed for an indefinite term, do you have any known limitations on your willingness or ability to serve for the foreseeable future? ____Yes. If so, please explain: No (c) If you have previously held any Schedule C or other appointive position in the Executive branch, irrespective of whether the position required Congressional confirmation, please state the circumstances of your departure and its timing. Sierra Club v. EPA 18cv3472 NDCA Tier 1 ED 002061 00170008-00005 UNITED STATES SENATE COMMITTEE ON ENVIRONMENT AND PUBLIC WORKS STATEMENT FOR COMPLETION BY PRESIDENTIAL NOMINEES Financial Statement: Note: The Office of Government Ethics will provide the Committee with a copy of your Executive Personnel Financial Disclosure Report (SF-278). 1. List sources, amounts and dates of all anticipated receipts from deferred income arrangements, stock options, uncompleted contracts and other future benefits which you expect to derive from previous business relationships, professional services and firm memberships or from former employers, clients, and customers. Amounts should be indicated by the categories established for reporting income on Form SF-278, Schedule A. 2. Are any assets pledged? ____Yes. If so, please explain: ____No 3. Are you currently a party to any legal action? ____Yes. If so, please explain: ____No 4. Have you filed a Federal income tax return for each of the last 10 years? If not, please explain the circumstances. ____Yes ____No. If not, please explain: 5. Has the Internal Revenue Service ever audited your Federal tax return? Yes. If so, what resulted from the audit? No Sierra Club v. EPA 18cv3472 NDCA Tier 1 ED 002061 00170008-00006 UNITED STATES SENATE COMMITTEE ON ENVIRONMENT AND PUBLIC WORKS STATEMENT FOR COMPLETION BY PRESIDENTIAL NOMINEES Potential conflicts of interest: 1. Describe any financial or deferred compensation agreements or other continuing of interest: dealings with business associates, clients or customers who will be affected by policies which you will influence in the position to which you have been nominated. 2. List any investments, obligations, liabilities, or other relationships which might involve potential conflicts of interest, or the appearance of conflicts of interest, with the position to which you have been nominated. 3. Describe any business relationship, dealing or financial transaction (other than taxpaying) which you have had during the last 10 years with the Federal Government, whether for yourself or relatives, on behalf of a client, or acting as an agent, that might in any way constitute or result in a possible conflict of interest, or an appearance of conflict of interest, with the position to which you have been nominated. 4. Explain how you will resolve any potential conflict of interest, or appearance of a conflict of interest, that may be disclosed by your responses to the above items. 5. Explain how you will comply with conflict of interest laws and regulations applicable to the position for which you have been nominated. Attach a statement from the appropriate agency official indicating what those laws and regulations are and how you will comply with them. For this purpose, you may utilize a statement by the relevant agency Ethics Officer. Sierra Club v. EPA 18cv3472 NDCA Tier 1 ED 002061 00170008-00007 UNITED STATES SENATE COMMITTEE ON ENVIRONMENT AND PUBLIC WORKS STATEMENT FOR COMPLETION BY PRESIDENTIAL NOMINEES Political affiliation and activities: List all memberships and offices held in, or financial contributions (in excess of $1,000), and services rendered to any political party or election committee during the last 10 years. Membership/Office/Political Party Dates Amount (if applicable) Published writings: List the titles, publishers and dates of any books, articles, or reports you have written. (Please list first any publications and/or speeches that involve environmental or related matters.) Additional Matters: 1. If there is any additional information which you believe may be pertinent to the Members of the Committee in reaching their decisions, you may include that here. 2. Do you agree to appear before all Congressional Committees which seek your testimony? Yes ____ No. If not, please explain: Sierra Club v. EPA 18cv3472 NDCA Tier 1 ED 002061 00170008-00008 UNITED STATES SENATE COMMITTEE ON ENVIRONMENT AND PUBLIC WORKS STATEMENT FOR COMPLETION BY PRESIDENTIAL NOMINEES 3. Having completed this form, are there any additional questions which you believe the Committee should ask of future nominees? ___ Yes. If so, please explain: No AFFIDAVIT ) ss, being duly sworn, hereby states that he/she has read and signed the foregoing Statement for Completion by Presidential Nominees including the Financial Statement and that the information provided therein is, to the best of his/her knowledge and belief, current, accurate, and complete. Subscribed and sworn before me this day of ,20. Notary Public Sierra Club v. EPA 18cv3472 NDCA Tier 1 ED 002061 00170008-00009