OGE Form 202: Notice of Conflict of Interest Referral

• Date: 01 January 2016
• Section: Office of Government Ethics (OGE)

OGE FORM 202(rev. 10/16)

OGE FORM 202, PART 1

NOTIFICATION OF CONFLICT OF INTEREST REFERRAL

PART 1: INITIAL NOTIFICATION

(to be filed by the referring office)

File Part 1 of thisform with the U.S. Office of Government Ethics(OGE) upon any referralmade to the

U.S.Department of Justice(DOJ), pursuant to 28 U.S.C. § 535,involving:

(1)A possible violation under section 203, 205, 207, 208, and/or 209of title 18, United States Code;

(2)A civil or criminal matter related to the filing or non-filing of a financial disclosure report under

applicable legal authorities (e.g., 5 U.S.C. app. § 104 or 18 U.S.C. §1001); or

(3)A civil matter involving outside earned income under 5 U.S.C. app. § 501 or outside activities under

5 U.S.C. app. § 502.

Submitthis formvia email toreferrals@oge.gov. OGE will confirm receipt and notify the referring office of

the OGE tracking number assigned.

1.Federal office referring the matter to the Department of Justice:2.Date of referral:

3.Point of contact at the referring office:

Name: Title:

Telephone: Email:

4.Tracking/investigation number assigned by the referring office:

5.Department of Justice office to which the matter was referred:

Public Integrity Section, Criminal Division

U.S. Attorney (specify district)

Other DOJ office (specify office)

OGE use only

OGE tracking number: Date received: