Appendix B to Part 2634 - Certificate of Compliance (Form Approved: OMB Control No. 3209-0007)

Appendix B to Part 2634 - Certificate of Compliance (Form Approved: OMB Control No. 3209-0007)

The Certificate of Compliance required by § 2634.408(d)(4) shall be executed as follows:

Certificate of Compliance

With respect to the qualified blind trust (qualified diversified trust) of___ (Settlor), the undersigned, the approved [Trustee] [___] of such trust, pursuant to 5 CFR 2634.405, has served in such fiduciary capacity during the calendar year [or for the period beginning___ and ending___] and is eligible to continue in such capacity by virtue of the following:

FIRST: The undersigned (and any director, officer, or employee) has not knowingly or negligently, and will not -

(A) disclose any information to an interested party with respect to the trust that may not be disclosed pursuant to title I of the Act, the implementing regulations (including 5 CFR 2634.408(d)(1)(i)), or the trust instrument;

(B) acquire any holding the ownership of which is prohibited by, or not in accordance with, applicable statute, regulation, or the terms of the trust instrument;

(C) solicit advice from any interested party with respect to such trust, which solicitation is prohibited by title I of the Act, the implementing regulations (including 5 CFR 2634.408(d)(1)(iii)), or the trust instrument;

(D) fail to file any document required by title I of the Act, the implementing regulations (5 CFR 2634.408), or the trust instrument; or

(E) violate or fail to comply with any provision or requirement of title I of the Act, the implementing regulations, or the trust instrument.

SECOND: The undersigned (and any director, officer, or employee) will not knowingly or negligently engage in the above-mentioned activities.

THIRD: The undersigned certifies that the statements contained herein are true, complete and correct to the best of such undersigned's knowledge and belief.

Date___

(firm)___

By:___

(title)___

Note:

See appendix C of this part for Privacy Act and Paperwork Reduction Act notices.

[57 FR 11830, Apr. 7, 1992; 57 FR 21855, May 22, 1992, as amended at 77 FR 39150, July 2, 2012]