Code of Federal Regulations Title 10. Energy 10 CFR Pt. 1050, App. I—Foreign Gifts Statement

1.

Name of Employee

2.

Date

3.

Division

4.

Position

5.

Name of Recipient

6.

Relationship to Employee

7.

Description of Gift

8.

Date of Acceptance

9.

Value of Gift

10.

Circumstances Justifying Acceptance of the Gift

11.

Foreign Government Donor

12a.

Name of Individual Presenting Gift

12b.

Position of Individual Presenting Gift

13.

Do you wish to participate in the sale of this item if it is sold by GSA?

☐ Yes

☐ No

Signature of Recipient

Date

Item 1.

This statement is to be filed pursuant to the provisions of the Foreign Gifts and Decorations Act (5 U.S.C. 7342, as amended by Pub. L. 95-105, August 17, 1977) and DOE implementing regulations at 10 CFR part 1050. These provisions apply to foreign gifts tendered to or accepted by Federal employees and their spouses and dependents. The name of the employee should always be indicated in item 1; if the employee is the recipient of the gift then items 5 and 6 should be marked N/A-not applicable; if the recipient is a spouse or dependent, then the appropriate information should be included in items 5 and 6.

Item 2.

Self explanatory.

Items 3 and 4. The Office or Division and the position of the employee should be indicated here regardless of whether the recipient is the employee or a spouse or dependent.

Items 5 and 6. See above, Item 1.

Item 7.

Self explanatory.

Item 8.

Self explanatory.

Item 9.

Indicate the retail value in the United States at the time of acceptance. If there is any uncertainty as to the value of the gift, it is the recipient's responsibility to make a reasonable effort to determine value. If the value is $100 or under, and if the aggregate value of the gifts accepted by the recipient from all sources over any period of one year does not exceed $250, then the gift may be retained by the recipient and this Statement need not be submitted.

Item 10.

Identify in this item whether or not approval to accept the gift was sought or given in advance in accordance with Section 1050.204 of the DOE regulations. Also identify those circumstances supporting a determination that refusal of the gift would likely cause offense or embarrassment or otherwise adversely affect the foreign relations of the United States.

Items 11 and 12. Self explanatory.

Item 13.

Though there is no assurance that the item will be sold or if it is sold that it will be feasible for the recipient to participate in the sale, GSA regulations provide for participation by the recipient where feasible.