Certificate of Divestiture Request Format

• Date: 27 August 2019
• Section: Office of Government Ethics (OGE)

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REQUESTFOR A CERTIFICATE OF DIVESTITURE

(must be completed bythe agency, notby the requestingemployee)

Requesting employee’s name and position title: Employing agency and component:

Agency point of contact: Telephone number and email address for agency

pointof contact:

Signature ofDAEO or ADAEO: Date signed:

For complete instructions on requesting a Certificate of Divestiture (CD), please review 5 C.F.R. part

2634, subpart J.

1.

Provide the requested information aboutthe

property being divested and the owner(s) of that

property (see sample table to the right):

(a)

description of the property: include the name oftheproperty

being divested;

(b)

quantity or percentage owned: quantity may berepresented

by the number of shares of stock, units owned,

or percentage of the partnership owned;

(c)

owner(s) of the property: provide the full name of the

owner(s) of the property; and

(d)

relationship to the employee: indicate whether each property

owner is one of the following: (i) a government employee; (ii) a

spouse, a minor child or a dependent child of the government

employee; or (iii) a trustee of a trust for the benefit of the

government employee, the spouse, minor or dependent child of

the government employee.

Please provide the requested information in an Excel spreadsheet or Word document if a CD is being requested

for more than six holdings. Please do not submit financial statements.

(a)Description of the property(b)Quantity or

percentage

owned

(c)Owner(s) of

theproperty(d)Relationship to

theemployee

(a)Description

of the property(b)Quantity

or

percentage

owned

(c)Owner(s)

of the

property

(d)Relationship

to the employee

McDonald’s

Corp.

57 shares

John A.

Jones

self

General Electric

Co.

251 sharesJohn A.

Jones (joint)

Mary B. Jones

self

spouse

Play Toys, LP12.24%

interestMary B.

Jones spouse

Merck & Co.,

Inc.

33 shares

William C.

Smith

trustee

Coca-Cola, Co.55 shares

John A.

Jones (as

custodian)

Robert D.

Jones

self

dependent child

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