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• Assets held for investment or the production of income that ended
the reporting period with a value greater than $1,000. In addition,
annual filers must report assets from which more than $1,000 in
income was received during the reporting period. Reportable assets
include, but are not limited to:
- Assets, such as stocks, bonds, annuities, trust holdings, partnership
interests, life insurance, investment real estate, and privately held
trades or businesses
- Sector mutual funds: those funds invested in a particular industry,
business, or location, such as ABC Financial Fund, XYZ Energy
Fund, or AVC Healthcare Fund (report the full name of the sector
fund, not just the family fund name)
- Holdings of retirement plans, such as 401(k)s, IRAs, and variable
annuities (report each holding unless listed in the Do Not Report
section)
- Defined benefit pension plans provided by a former non-Federal
employer (include the name of the employer)
• Diversified mutual funds, such as ABC Equity Value Fund or XYZ
Large Capital Fund
• Federal Government retirement benefits
• Thrift Savings Plan
• Certificates of deposit, savings or checking accounts
• Term life insurance
• Money market mutual funds and money market accounts
• Your personal residence, unless you rent it out
• U.S. Treasury bonds, bills, notes, and savings bonds
• Diversified funds within an employee benefit plan
• Money owed to you, your spouse, or dependent child by a spouse,
parent, sibling, or child
Do not report account or Social Security numbers or names of
family members
Employee’s Name (Print last, first, middle initial)
Part I: Assets and Income
Report for Yourself, Spouse, and Dependent Child:
Do Not Report:
XYZ 401(k) Plan (Alternative example of a sector fund in a 401(k), or other
retirement or brokerage account
)
Also Report:
Do Not Report:
• For yourself: (1) all sources of salary, fees, commissions, and other
earned income greater than $1,000, (2) honoraria greater than $1,000,
and (3) other non-investment income, such as scholarships, prizes,
and gambling income greater than $1,000
• For your spouse: (1) all sources of salary, fees, commissions, and
other earned income greater than $1,000, and (2) honoraria greater
than $1,000
• Dependent child’s earned income (e.g., wages, fees)
• Veterans' benefits
• Federal Government salary
• Social Security benefits
Dependent Child – A son, daughter, stepson, or stepdaughter who is either unmarried, under age 21, and living in the filer’s house,
or considered dependent under the U.S. tax code.
Reportable Information
Report the full name of each individual asset, such as a stock, bond, or sector mutual fund. (You may add the
ticker symbol to the asset name.) This includes any asset that is an underlying holding of a trust, retirement, or
investment account that meets the reporting requirement. Report the type and location of any investment real estate.
Report name of employer or business, source of fees, commissions, or honoraria. (Include a brief description.)
You may distinguish any entry for a family member by preceding it with (S) for spouse or (DC) for dependent child.
EXAMPLES — Go to the last page to see additional examples of how to report assets and income.
OGC Widgets, Inc. (OGC) (Example of a stock with a ticker symbol )
(S) Express Medical Clinic — salary (Example of spouse's earned income from a current employer)
ABC Healthcare Fund (Example of a sector fund held in a 401(k) plan, IRA, or brokerage account )
- XYZ Energy Fund
- Rock Financial Fund
CA (ScholarShare) College Savings Plan: Age 0-5 Portfolio (Example of a 529 college savings plan with underlying investment)
OGE Form 450, 5 CFR Part 2634, Subpart I
U.S. Office of Government Ethics (08/2024)
Expires 08/31/2027
Form Approved
OMB No. 3209-0006