NOTIFICATION OF CONFLICT OF INTEREST REFERRAL

• Document Type: FOIA
• Collection: FOIA Collection
• Document Number (FOIA) /ESDN (CREST): 07091013
• Release Decision: RIPPUB
• Original Classification: U
• Document Page Count: 29
• Document Creation Date: July 31, 2024
• Document Release Date: June 30, 2024
• Case Number: F-2024-00295

Approved for Release: 2024/06/27 C07091013
OGE FORM 202, PART 1
NOTIFICATION OF CONFLICT OF INTEREST REFERRAL
PART 1: INITIAL NOTIFICATION
(to be filed by the refining office)
File Part 1 of this form with the U.S. Office of Government Ethics (OGE) upon any referral made to the
U.S. Department of Justice (DOM pursuant to 28 U.S.C. � 535, involving:
(1) A possible violation under section 203, 205, 207, 208, and/or 209 of 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.
Submit this form via email to [e-mail]. 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:
CIA Office of Inspector General
(b)(6
(b)(7)(c) 3. Point of contact at the referring office:
(b)(3) CIAAct
IN ame:
(b)(3) CIAAobhone:
Tide: Special Agent
4. Tracking/investigation number assigned by the referring office:
(b)(3) CIAAct
5. Department of Justice office to which the matter was referred:
Public Integrity Section, Criminal Division
U.S. Attorney (4,46, district) Eastern District of Virginia
nOther DOJ office (spec 6 office)
OGE use onl
OGE tracking number:
Date received:
2. Date of referral:
6 September 2023
(b)(6)
(b)(7)(c)
(b)(3) CIAAct
OGE FORM 202 (rev. 10/16)
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OGE FORM 202, PART 2
NOTIFICATION OF CONFLICT OF INTEREST REFERRAL
PART 2: DISPOSITION OF REFERRAL
(to be filed by the referring office)
File Part 2 of this form with the U.S. Office of Government Ethics (OGE) following the referral made to the
U.S. Department of Justice (DOJ), pursuant to 28 U.S.C. � 535, after both of the following have occurred:
(1) DOJ has (a) declined prosecution; (b) initiated prosecution or taken other legal action that is a matter
of public record; or (c) settled the matter through formal agreement; and
(2) Investigation of the matter has concluded.
Submit this form via email to [e-mail]. OGE will confirm receipt.
1. Federal office referring the matter to the Department of Justice:
2. Point of contact at the referring office:
Name:
Telephone:
Title:
Email:
3. Tracking/investigation number assigned by the referring office:
4. OGE tracking number:
5. Statutes involved in the matter (mark all that apply):
18 U.S.C. � 203 1718 U.S.C. � 1001 (in connection with financial disclosure or other ethics documents only)
18 U.S.C. � 205
n5 U.S.C. app. � 104 (financial disclosure)
18 U.S.C. � 207 F15 U.S.C. app. � 501 (outside earned income)
18 U.S.C. � 208
F718 U.S.C. � 209
5 U.S.C. app. � 502 (outside activities)
Other (Jpeci):
OGE FORM 202 (rev. 10/16)
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6. Disposition of the referral to DOJ:
7. Has there been an adverse finding regarding the employee involved related to the Standards of Ethical
Conduct for Employees of the Executive Branch (5 C.F.R. part 2635) or agency supplemental standards of
conduct?
Oyes (complete boxes 8-12 below)
Ono (do not complete the rest of this fair!)
If the res a onse in box 7 is" es," corn lete boxes 8-12, below.
8. Name and title of the employee or former employee involved:
9. Agency component where the employee/former employee is/was employed:
10. Has the employing agency considered taking corrective action against the employee?
Oyes
Ono
()unknown
11. Have you elected to attach either a report of investigation or summary?
eyes
Ono
12. (optional) Provide any other information you consider pertinent:
OGE FORM 202 (rev. 10/16)
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OGE FORM 202, PART 3
NOTIFICATION OF CONFLICT OF INTEREST REFERRAL
PART 3: CONSIDERATION OF CORRECT WE ACTION
(to be filed by the DAEO of the employing ageng or the DAEO's designee)
File Part 3 of this form with the U.S. Office of Government Ethics (OGE) following the referral made to the
U.S. Department of Justice (DM, pursuant to 28 U.S.C. � 535, after all of the following have occurred:
(1) DOJ has (a) declined prosecution; (b) initiated prosecution or taken other legal action that is a matter
of public record; or (c) settled the matter through formal agreement;
(2) Investigation of the matter has concluded; and
(3) The referring office has made an adverse finding regarding the employee involved related to the
Standards of Ethical Conduct for Employees of the Executive Branch or any agency supplemental
standards of conduct.
Submit this form via email to [e-mail]. OGE will confirm receipt.
OGE use onl
Referring office tracking/investigation number:
OGE tracking number:
Name of agency employee involved:
Agency:
Name of Designated Agency Ethics Official:
Telephone:
Name of OGE point of contact:
Telephone:
I. Whether or not action is warranted, provide the name and title of the agency official who has authority to
take disciplinary or correction action with regard to the employee involved.
Name: Title:
2. Has disciplinary or other corrective action been either initiated (e .g. , advance written notice issued pursuant
to 5 U.S.C. � 7513) or taken?
Oyes (describe action below, then skip to box 4) Ono
Describe any disciplinary action or other corrective action initiated or taken:
OGE FORM 202 (rev. 10/16)
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3. If disciplinary or other corrective action has not been initiated or taken, did the official identified in box 1,
above, actively consider whether such action was warranted before affirmatively deciding not to take action?
0 yes
C")no (explain why not below)
If the response in box 3 is "no," explain why not:
Mark this box if additional sheets or documents are attached.
nAttachments
4. Name, tide and contact information of DAEO or DAEO's designee signing this form:
Name: Tide:
Telephone:
Email:
5. I certify that I have exercised due diligence in gathering the requested information and that the information
provided in this form is accurate and complete to the best of my information and belief.
Signature
Date
OGE FORM 202 (rev. 10/16)
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OGE FORM 202, PART 1
NOTIFICATION OF CONFLICT OF INTEREST REFERRAL
PART I: INITIAL NOTIFICATION
(to be _filed by the r!ierrrns office)
File Part 1 of this form with the U.S. Office of Government Ethics (OGE) upon any referral made to the
U.S. Department of Justice (1)0J), pursuant to 28 U.S.C. � 535, involving:
(1) A possible violation under section 203, 205, 207, 208, and/or 209 of 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.
Submit this form via email to [e-mail]. OGE will confirm receipt and notify the referring office of
the OGE tracking number assigned.
(b)(6)
(b)(7)(c)
(b)(3) CIAActlame:
Telephone:
1. Federal office referring the matter to the Department ofjustice:
CIA OIG
3. Point of contact at the referring office:
(b)(3) CIAAct
Special Agent
Title:
Email:
2. Date of referral:
9 June 23
(b)(6)
(b)(7)(c)
(b)(3) CIAAct
4. Trackin investigation number assigned by the referring office:
(b"3) CIAAINNEMININIMINOMINIONMENNERMEN.
5. Department of Justice office to which the matter was referred:
FlPublic Integrity Section, Criminal Division
U.S. Attorney (ipetiji, dishict) Eastern District of Virginia
Other D0.1 office (04, eke)
OGE use only
OGE tracking munbec Date received:
OGE FC)RM 202 (rev. 10/16)
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(b)(6)
(b)(7)(c)
OGE FORM 202, PART 2
NOTIFICATION OF CONFLICT OF INTEREST REFERRAL
PART 2: DISPOSITION OF REFERRAL
(to bellied by the 1V-erring office)
File Part 2 of this form with the U.S. Office of Government Ethics (OGE) following the referral made to the
U.S. Department of justice (D0J), pursuant to 28 U.S.C. � 535, after both of the following have occurred:
(1) D21 has (a) declined prosecution; (b) initiated prosecution or taken other legal action that is a matter
of public record; or (c) settled the matter through formal agreement; and
(2) Investigation of the matter has concluded.
Submit this form via email to [e-mail]. OGE will confirm receipt.
1. Federal office referring the matter to the Department of justice:
CIA OIG
2. Point of contact at the referring office:
(b)(3) CIAAct
IN ame:
Telephone:
(b)(3) CIAAct
Special Agent
Title:
Email:
3. Trackin /investigation number assigned by the referring office:
(b)(3) CIAAct
4. OGE tracking number:
5. Statutes involved in the matter (mark all that appty):
E 18 U.S.C. � 203
18 U.S.C. � 205
018 U.S.C. � 207
17118 U.S.C. � 208
1118 U.S.C. � 209
18 U.S.C. � 1001 (in connection with financial disclosun, or other ethics domments onA)
5 U.S.C. app. � 104 (financial disclosnre)
5 U.S.C. app. � 501 (outside earned income)
F-15 U.S.C. app. � 502 (on/side adtrilies)
[1 Other (Jpetiii):
OGE FORM 202 (rev. 10/16) Page 1 of 2
(b)(6)
(b)(7)(c)
(b)(3) CIAAct
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6. Disposition of the referral to DOJ:
Declined to Prosecute
7. Has there been an adverse finding regarding the employee involved related to the Standards of Ethical
Conduct for Employees of the Executive Branch (5 C.F.R. part 2635) or agency supplemental standards of
conduct?
�yes (coo4Vete boxes 812 below)
Ono (do not complete the nut of dds.form)
If the response in box 7 is es," complete boxes 8-12, below.
8. Name and title of the employee or former employee involved:
9. Agency component where the employee/former employee is/was employed:
Directorate of Science & Technology
10. Has the employing agency considered taking corrective action against the employee?
Oyes
Ono �unknown
11. Have you elected to attach either a report of investigation or summary?
Oyes �no
12. (optional) Provide any other information you consider pertinent:
OGE FORM 202 (rev. 10/16)
(b)(6)
(b)(7)(c)
(b)(3) CIAAct
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OGE FORM 202, PART 3
NOTIFICATION OF CONFLICT OF INTEREST REFERRAL
PART 3: CONSIDERATION OF CORRECTIVE ACTION
(to be filed by the DAEO of the employiqa,gency or the 121tO c designee
File Part 3 of this form with the U.S. Office of Government Ethics (OGE) following the referral made to the
U.S. Department of Justice (DO!), pursuant to 28 U.S.C. � 535, after all of the following have occurred:
(1) DOJ has (a) declined prosecution; (b) initiated prosecution or taken other legal action that is a matter
of public record; or (c) settled the matter through formal agreement;
(2) Investigation of the matter has concluded; and
(3) The referring office has made an adverse finding regarding the employee involved related to the
Standards of Ethical Conduct for Employees of the Executive Branch or any agency supplemental
standards of conduct.
Submit this form via email to [e-mail]. OGE will confirm receipt.
OGE use onl
Referriiig office on number:
OGE tracking number:
Name of agency employee involved:
Agency:
Name of Designated Agency Ethics Official:
Telephone:
Name of OGE point of contact:
Telephone:
1. Whether or not action is warranted, provide the name and title of the agency official who has authority to
take disciplinary or correction action with regard to the employee involved.
Name: Title:
2. Has disciplinary or other corrective action been either initiated (e.s., advance written notice issued pursuant
to 5 U.S.C. � 7513) or taken?
Oyes (describe action below, then skip to box 4)
Describe any disciplinary action or other corrective action initiated or taken:
CX.11;. FORM 202 (rev. 10/16)
On�
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3. If disciplinary or other corrective action has not been initiated or taken, did the official identified in box 1,
above, actively consider whether such action was warranted before affirmatively deciding not to take action?
oyes
Ono (iVlain inIfy not below)
If the response in box 3 is "no," explain why not:
Mark this box if additional sheets or documents are attached.
riAttachments
4. Name, title and contact information of DAEO or DAEO's designee signing this form:
Name:
Telephone:
Title!
Email:
5. I certify that I have exercised due diligence in gathering the requested information and that the information
provided in this form is accurate and complete to the best of my information and belief.
Signature
OG F. FORM 202 (rev. 10/16)
Date
Page 2 of 2
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OGE FORM 202, PART
NOTIFICATION OF CONFLICT OF INTEREST REFERRAL
PART 1: INITIAL NOTIFICATION
(to be filed by the Itflening office)
File Part 1 of this form with the U.S. Office of Government Ethics (OGE) upon any referral made to the
U.S. Department of Justice (D0j), pursuant to 28 U.S.C. � 535, involving:
(1) A possible violation under section 203, 205, 207, 208, and/or 209 of tide 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.
Submit this form via email to referrals@oge.g(w. 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:
CIA Office of Inspector General
(b)(6)
(b)(7)(c) 3. Point of contact at the referring office:
(b)(3) CIAAct
Name:
Telephone:
(b)(3) CIAAct
Special Agent
Title:
Email:
4. Tracking/investigation number assigned by the referring office:
(b)(3) CIAAct
5. Department of Justice office to which the matter was referred:
LIPublic Integrity Section, Criminal Division
Eastern District of Virginia
U.S. Attorney (Jpecfb, district)
EllOther DOJ office (oeit office)
OGE use only
OGE tracking number Date received:
OGE FORM 202 (rev. 10/16)
2. Date of referral:
21 June 2022
(b)(6)
(b)(7)(c
(b)(3) CIAAct
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OGE FORM 202, PART 2
NOTIFICATION OF CONFLICT OF INTEREST REFERRAL
PART 2: DISPOSITION OF REFERRAL
(to be _filed by the ryfertiq office)
File Part 2 of this form with the U.S. Office of Government Ethics (OGE) following the referral made to the
U.S. Department of Justice (DOD, pursuant to 28 U.S.C. � 535, after both of the following have occurred:
(1) DOJ has (a) declined prosecution; (b) initiated prosecution or taken other legal action that is a matter
of public record; or (c) settled the matter through formal agreement; and
(2) Investigation of the matter has concluded.
Submit this form via email to [e-mail]. OGE will confirm receipt.
1. Federal office referring the matter to the Department of Justice:
CIA Office of Inspector General
(b)(6)
(b)(7)(c)
(b)(3) CIAActme:
Telephone:
2. Point of contact at the referring office:
(b)(3) CIAAct
Special Agent
Tide:
Email:
3. Trackin investi tion number assigned by the referring office:
(b)(3) CIAAct
4. OGE tracking number:
OG E-2023-0492
5. Statutes involved in the matter (mark al/that app/y):
018 U.S.C. � 203
El8 U.S.C. � 205
r-718 U.S.C. 207
Z18 U.S.C. � 208
El8 U.S.C. � 209
OGE FORM 202 (rev. 10/16)
18 U.S.C. � 1001 (in connection with financial disclosure or other ethics documents on)
1115 U.S.C. app. � 104 (financial disclosure)
5 U.S.C. app. � 501 (outside earned income)
IlI5 U.S.C. app. � 502 (outside act/Pities)
ri Other (Jperin):
(b)(6)
(b)(7)(c)
(b)(3) CIAAct
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6. Disposition of the referral to DOJ:
DOJ declined to prosecute this case.
7. Has there been an adverse finding regarding the employee involved related to the Standards of Ethical
Conduct for Employees of the Executive Branch (5 C.F.R. part 2635) or agency supplemental standards of
conduct?
eyes (complele boxes 8-12 below)
0 no (do no1 complete The resl of this form)
If the res onse in box 7 is" corn lete boxes 8-12, below.
8. Name and title of the employee or former employee involved:
9. Agency component where the employee/former employee is/was employed:
10. Has the employing agency considered taking corrective action against the employee?
Oyes
Ono ()unknown
11. Have you elected to attach either a report of investigation or summary?
Oyes
12. (optional) Provide any other information you consider pertinent:
N/A
OGE FORM 202 (rev. 10/16)
Page 2 of 2
(b)(3)
CIAAct
(b)(3) I
CIAAct
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OGE FORM 202, PART 3
NOTIFICATION OF CONFLICT OF INTEREST REFERRAL
PART 3: CONSIDERATION OF CORRECTIVE ACTION
(to be filed by the DAEO of the employing ggeno, or the DAEO's tiest:gnee)
File Part 3 of this form with the U.S. Office of Government Ethics (OGE) following the referral made to the
U.S. Department of Justice (D0j), pursuant to 28 U.S.C. � 535, after all of the following have occurred:
(1) DOJ has (a) declined prosecution; (b) initiated prosecution or taken other legal action that is a matter
of public record; or (c) settled the matter through formal agreement;
(2) Investigation of the matter has concluded; and
(3) The referring office has made an adverse finding regarding the employee involved related to the
Standards of Ethical Conduct for Employees of the Executive Branch or any agency supplemental
standards of conduct.
Submit this form via email to [e-mail]. OGE will confirm receipt.
OGE use onl
Referring office number:
OGE tracking number:
Name of agency employee involved:
Agency:
Name o( Designated Ethics Official:
Telephone:
Name of OGE point of contact
Telephone:
1. Whether or not action is warranted, provide the name and tide of the agency official who has authority to
(b)(6)
(b)(7)(c) Name:
(b)(3) CIAAct
take disciplinary or correction action with regard to the employee involved.
Title:
2. Has disciplinary or other corrective action been either initiated (e.g., advance written notice issued pursuant
to 5 U.S.C. � 7513) or taken?
eyes (describe action below, then skip to box 4) Ono
Describe any disciplinary action or other corrective action initiated or taken:
CIA/01G is in the process of drafting a final investigative report that will be issued to CIA
leadership for their consideration of the most appropriate disciplinary or other corrective action.
OGE FORM 202 (rev. 10/16)
Page 1 of 2
(b)(3)
CIAAct
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3. If disciplinary or other corrective action has not been initiated or taken, did the official identified in box 1,
above, actively consider whether such action was warranted before affirmatively deciding not to take action?
0 yes 0 no (volain ivly not below)
If the response in box 3 is "no," explain why not:
N/A
Mark this box if additional sheets or documents are attached.
EliAttachments
(b)(6)
(b)(7)(c) 4. Name, tide and contact information of DAEO or DAEO's designee signing this form:
(b)(3) CIAAceame: Title: Chief of CIA, Office of General Counsel, Ethics
Law Division
(b)(3) CIAAct
Email:
(b)(6)
Telephone:
(b)(3) CIAAct
5. I certify that I have exercised due diligence in gathering the requested information and that the information
provided in this form is accurate and complete to the best of my information and belief.
(b)(7)(c)
(b)(3) CIAAct
Signature
OG F: FORM 202 (rev. 10/16)
16 J...t cal
Date
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Approved for Release: 2024/06/27 C07091013
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 this form with the U.S. Office of Government Ethics (OGE) upon any referral made to the
U.S. Department of Justice (DOD, pursuant to 28 U.S.C. � 535, involving:
(1) A possible violation under section 203, 205, 207, 208, and/or 209 of 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.
Submit this form via email to [e-mail]. 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:
CIA/01G
(b)(6)
(b)(7)(c) 3. Point of contact at the referring office:
(b)(3) CIAActime.
Telephone:
(b)(3) CIAAct
Special Agent
Title:
Email:
4. Tracking/investigation number assigned by the referring office:
5. Department of Justice office to which the matter was referred:
I.
Public Integrity Section, Criminal Division
FlU.S. Attorney (specify district)
Other DOJ office (oeci:A office)
OGE use onl
OGE tracking number:
Date received:
2. Date of referral:
7 July 2023
(b)(6)
(b)(7)(c
(b)(3) CIAAct
1
(b)(3) CIAAct
OGE FORM 202 (rev. 10/16)
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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 this form with the U.S. Office of Government Ethics (OGE) upon any referral made to the
U.S. Department of Justice (DOD, pursuant to 28 U.S.C. � 535, involving:
(1) A possible violation under section 203, 205, 207, 208, and/or 209 of 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.
Submit this form via email to [e-mail]. 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:
CIA Office of Inspector General
(b)(6)
(b)(7)(c) 3. Point of contact at the referring office:
(b)(3) CIAAct
IN ame:
Telephone
Special Agent
(b)(3) CIAActErnail:
2. Date of referral:
21 June 2022
4. Tracking/investigation number assigned by the referring office:
(b)(3) CIAAct
5. Department of Justice office to which the matter was referred:
riPublic Integrity Section, Criminal Division
Eastern District of Virginia
Attorney (speciA district)
Other DOJ office (.0ec6i office)
OGE use onl
OGE tracking number:
Date received:
(b)(6)
(b)(7)(c)
(b)(3) CIAAct
OGE FORM 202 (rev. 10/16)
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OGE FORM 202, PART 2
NOTIFICATION OF CONFLICT OF INTEREST REFERRAL
PART 2: DISPOSITION OF REFERRAL
(to be filed by the referring office)
File Part 2 of this form with the U.S. Office of Government Ethics (OGE) following the referral made to the
U.S. Department of Justice (DOD, pursuant to 28 U.S.C. � 535, after both of the following have occurred:
(1) DOJ has (a) declined prosecution; (b) initiated prosecution or taken other legal action that is a matter
of public record; or (c) settled the matter through formal agreement; and
(2) Investigation of the matter has concluded.
Submit this form via email to referralsgoge.gov. OGE will confirm receipt.
1. Federal office referring the matter to the Department of Justice:
2. Point of contact at the referring office:
Name:
Telephone:
Tide:
Email:
3. Tracking/investigation number assigned by the referring office:
4. OGE tracking number:
5. Statutes involved in the matter (mark all that apply):
18 U.S.C. � 203 18 U.S.C. 5 1001 (in connection with financial disclosure or other ethics documents on#)
18 U.S.C. 5 205 n 5 U.S.C. app. 5 104 (financial disclosure)
F18 U.S.C. � 207 n 5 U.S.C. app. � 501 (outside earned income)
18 U.S.C. � 208 5 U.S.C. app. � 502 (outside activities)
18 U.S.C. 5 209 ri Other (.1pe461):
OGE FORM 202 (rev. 10/16)
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6. Disposition of the referral to DOJ:
7. Has there been an adverse finding regarding the employee involved related to the Standards of Ethical
Conduct for Employees of the Executive Branch (5 C.F.R. part 2635) or agency supplemental standards of
conduct?
eyes (complete boxes 8-12 belon) no (do not complete the rest of this form)
If the res onse in box 7 is "yes," corn siete boxes 8-12, below.
8. Name and tide of the employee or former employee involved:
9. Agency component where the employee/former employee is/was employed:
10. Has the employing agency considered taking corrective action against the employee?
oyes
Ono Ounknown
11. Have you elected to attach either a report of investigation or summary?
Oyes no
12. (optional) Provide any other information you consider pertinent:
OGE FORM 202 (rev. 10/16)
Page 2 of 2
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OGE FORM 202, PART 3
NOTIFICATION OF CONFLICT OF INTEREST REFERRAL
PART 3: CONSIDERATION OF CORRECTIVE ACTION
(to be filed by the DAEO of the employing ageng or the DAEO's designee)
File Part 3 of this form with the U.S. Office of Government Ethics (OGE) following the referral made to the
U.S. Department of Justice (DOD, pursuant to 28 U.S.C. � 535, after all of the following have occurred:
(1) DOI has (a) declined prosecution; (b) initiated prosecution or taken other legal action that is a matter
of public record; or (c) settled the matter through formal agreement;
(2) Investigation of the matter has concluded; and
(3) The referring office has made an adverse finding regarding the employee involved related to the
Standards of Ethical Conduct for Employees of the Executive Branch or any agency supplemental
standards of conduct.
Submit this form via email to [e-mail]. OGE will confirm receipt.
OGE use onl
Referring office tracking/investigation number:
OGE tracking number:
Name of agency employee involved:
Agency:
Name of Designated Agency Ethics Official:
Telephone:
Name of OGE point of contact:
Telephone:
1. Whether or not action is warranted, provide the name and title of the agency official who has authority to
take disciplinary or correction action with regard to the employee involved.
Name:
2. Has disciplinary or other corrective action been either initiated (e.g., advance written notice issued pursuant
to 5 U.S.C. � 7513) or taken?
Oyes (describe action below, then skip to box 4) Ono
Describe any disciplinary action or other corrective action initiated or taken:
OGE FORM 202 (rev. 10/16)
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3. If disciplinary or other corrective action has not been initiated or taken, did the official identified in box 1,
above, actively consider whether such action was warranted before affirmatively deciding not to take action?
yes
Ono (explain why not below)
If the response in box 3 is "no," explain why not:
Mark this box if additional sheets or documents are attached.
Attachments
4. Name, title and contact information of DAEO or DAEO's designee signing this form:
Name: Title:
Telephone:
Email:
5. I certify that I have exercised due diligence in gathering the requested information and that the information
provided in this form is accurate and complete to the best of my information and belief.
Signature
Date
OGE FORM 202 (rev. 10/16)
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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 this form with the U.S. Office of Government Ethics (OGE) upon any referral made to the
U.S. Department of Justice (D0J), pursuant to 28 U.S.C. � 535, involving:
(1) A possible violation under section 203, 205, 207, 208, and/or 209 of tide 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. � 13106 or 18 U.S.C. � 1001); or
(3) A civil matter involving outside earned income under 5 U.S.C. � 13143 or outside activities under 5
U.S.C. � 13144.
Submit this form via email to [e-mail]. 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:
CIA Office of Inspector General (CIA OIG)
(b)(6)
(b)(7)(c)
(b)(3) IAAcpint of contact at the referring office:
Name:
Telephone:
(b)(3) CIAAct
Tide:
2. Date of referral:
17 September 2019
CIA OIG Special Agent
Email:
4. Tracking/investigation number assigned by the referring office:
(b)(3) CIAAct
5. Department of Justice office to which the matter was referred:
Public Integrity Section, Criminal Division
Eastern District of Virginia (EDVA)
U.S. Attorney (.0ecifi district)
Other DOJ office (ipecify office)
OGE use onl
OGE tracking number:
Date received:
(b)(6)
(b)(7)(c)
(b)(3) CIAAct
OGE FORM 202 (rev. 06/23)
Approved for Release: 2024/06/27 C07091013
Approved for Release: 2024/06/27 C07091013
OGE FORM 202, PART 2
NOTIFICATION OF CONFLICT OF INTEREST REFERRAL
PART 2: DISPOSITION OF REFERRAL
(to be/i/ed by the referring office)
File Part 2 of this form with the U.S. Office of Government Ethics (OGE) following the referral made to the
U.S. Department of Justice (DOJ), pursuant to 28 U.S.C. � 535, after both of the following have occurred:
(1) DOJ has (a) declined prosecution; (b) initiated prosecution or taken other legal action that is a matter
of public record; or (c) settled the matter through formal agreement; and
(2) Investigation of the matter has concluded.
Submit this form via email to [e-mail]. OGE will confirm receipt.
1. Federal office referring the matter to the Department of Justice:
CIA Office of Inspector General (CIA OIG)
(b)(6)
(b)(7)(c) 2. Point of contact at the referring office:
(b)(3) CIAAct
Name
Telephone:
(b)(3) CIAAct
Assistant Special Agent in Charge
Title:
Email:
3. Tracking/investigation number assigned by the referring office:
(b)(3) CIAAct
4. OGE tracking number:
OGE-2019-0224
5. Statutes involved in the matter (mark all that apply):
18 U.S.C. � 203
18 U.S.C. � 205
18 U.S.C. � 207
18 U.S.C. � 208
18 U.S.C. � 209
18 U.S.C. � 1001 (in conneclion with financial disclosure or other ethics documents onA)
5 U.S.C. � 13106 (financial disclosure)
5 U.S.C. � 13143 (outside earned income)
5 U.S.C. � 13144 (outside activities)
Other (.9,e41):
(b)(6)
(b)(7)(c)
(b)(3) CIAAct
OGE FORM 202 (rev. 7/23)
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6. Disposition of the referral to DOJ:
DOJ has declined,
7. Has there been an adverse finding regarding the employee involved related to the Standards of Ethical
Conduct for Employees of the Executive Branch (5 C.F.R. part 2635) or agency supplemental standards of
conduct?
Oyes (complete boxes 8-12 below)
Ono (do not complete the rest of this form)
If the response in box 7 is "yes," complete boxes 8-12, below.
8. Name and title of the employee or former employee involved:
9. Agency component where the employee/former employee is/was employed:
Directorate of Operations
10. Has the employing agency considered taking corrective action against the employee?
eyes
Ono
()unknown
11. Have you elected to attach either a report of investigation or summary?
Oyes
�no
12. (optional) Provide any other information you consider pertinent:
OGE FORM 202 (rev. 7/23)
Page 2 of 2
(b)(3)
CIAAct
(b)(6)
(b)(7)(c)
(b)(3)
CIAAct
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Approved for Release: 2024/06/27 C07091013
OGE FORM 202, PART 3
NOTIFICATION OF CONFLICT OF INTEREST REFERRAL
PART 3: CONSIDERATION OF CORRECTIVE ACTION
(to be filed by the DAEO of the employing agency or the DAEO 's designee)
File Part 3 of this form with the U.S. Office of Government Ethics (OGE) following the referral made to the
U.S. Department of Justice (D0J), pursuant to 28 U.S.C. � 535, after all of the following have occurred:
(1) DOJ has (a) declined prosecution; (b) initiated prosecution or taken other legal action that is a matter
of public record; or (c) settled the matter through formal agreement;
(2) Investigation of the matter has concluded; and
(3) The referring office has made an adverse finding regarding the employee involved related to the
Standards of Ethical Conduct for Employees of the Executive Branch or any agency supplemental
standards of conduct.
Submit this form via email to [e-mail]. OGE will confirm receipt.
OGE use onl
Referring office tracking/investigation number:
OGE tracking number:
Name of agency employee involved:
Agency:
Name of Designated Agency Ethics Official:
Telephone:
Name of OGE point of contact:
Telephone:
1. Whether or not action is warranted, provide the name and title of the agency official who has authority to
take disciplinary or correction action with regard to the employee involved.
Name: Title:
2. Has disciplinary or other corrective action been either initiated (e g. , advance written notice issued pursuant
to 5 U.S.C. � 7513) or taken?
Oyes (describe action below, then skip to box 4)
Describe any disciplinary action or other corrective action initiated or taken:
Ono
OGE FORM 202 (rev. 10/16)
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3. If disciplinary or other corrective action has not been initiated or taken, did the official identified in box 1,
above, actively consider whether such action was warranted before affirmatively deciding not to take action?
If the response in box 3 is "no," explain why not:
Mark this box if additional sheets or documents are attached.
4. Name, title and contact information of DAEO or DAEO's designee signing this form:
5. I certify that I have exercised due diligence in gathering the requested information and that the information
provided in this form is accurate and complete to the best of my information and belief.
Approved for Release: 2024/06/27 C07091013
Approved for Release: 2024/06/27 C07091013
OGE FORM 202, PART 1
NOTIFICATION OF CONFLICT OF INTEREST REFERRAL
PART 1: INITIAL NOTIFICATION
(Io bellied by the nyNg office)
File Part 1 of this form with the U.S. Office of Government Ethics (OGE) upon any referral made to the
U.S. Department of Justice (1)01), pursuant to 28 U.S.C. � 535, involving:
(1) A possible violation Under section 203, 205, 207, 208, and/or 209 of 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.A., 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.
Submit this form via email to [e-mail]. OGE will confirm receipt and notify the referring office of
the OGE tracking number assigned.
(b)(6)
(b)(7)(c)
(b)(3) CIAActP_ oint of contact at the referring office:
(b)(3) CIAAct
1. Federal office referring the matter to the Department of Justice:
Central Intelligence Agency
Special Agent
Title:
2. Date of referral:
2 June 2023
4. Tracking/investigation number assigned by the referring office:
(b)(3) CIAAct
5. Department of justice office to which the matter was referred:
riPublic Integrity Section, Criminal Division
nU.S. Attorney (.0,4, &aria) Eastern District of Virginia
[III Other DOJ office (spet#i, eke)
OGE use only
OGE tracking number: Date received:
OG 1.1 I()RiN I 202 (rev. 1 0/ 1 6)
(b)(6)
(b)(7)(c)
(b)(3) CIAAct
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Approved for Release: 2024/06/27 C07091013
OGE FORM 202, PART 1
NOTIFICATION OF CONFLICT OF INTEREST REFERRAL
PART 1: INITIAL NOTIFICATION
(to be filed 4 the relenin,g
File Part 1 of this form with the U.S. Office of Government Ethics (OGE) upon any referral made to the
U.S. Department of Justice (DOJ), pursuant to 28 U.S.C. � 535, involving:
(I) A possible violation under section 203, 205, 207, 208, and/or 209 of 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. � 13106 or 18 U.S.C. � 1001); or
(3) A civil matter invoking outside earned income under 5 U.S.C. 5 13143 or outside activities under 5
U.S.C. � 13144.
Submit this form via email to [e-mail]. 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:
CIA Office of Inspector General
(b)(6)
(b)(7)(c)
Point of contact at the referring office:
(b)(3) CIAAct
Name. (b)(3) CIAAct Title:
Telephone.
Special Agent
Email:
4. Tracking/investigation number assigned by the referring office:
(b)(3) CIAAct
5. Department of Justice office to which the matter was referred:
[I] Public Integrity Section, Criminal Division
O, Eastern District of Virginia U.S. Attorney (speceft district)
[I] Other DOJ office (speciti, o//ice)
OGE useonly
OGE tracking number: Date received:
2. Date of referral:
30 Novemeber 2021
(b)(6)
(b)(7)(c)
(b)(3) CIAAct
OGE FORM 202 (rev. 06/23)
Approved for Release: 2024/06/27 C07091013