Part 3: Report YOUR retirement plan/account if it is sponsored by a former employer
▪ Report the name and location of your former employer.
▪ The language in the example below reflects the typical arrangement for a defined contribution plan. If your
arrangement is different, please contact your agency ethics office.
▪ Enter the date that you began participating in the plan.
▪ IRAs do not need to be reported in Part 3.
Part 5: Report YOUR SPOUSE’s retirement plan/account, underlying assets, and
distributions
Plan or Account
▪ Report the plan/account type (and the name of the employer/sponsor if there is one) in the description field.
The EIF field should be marked “No.”
▪ Enter the exact amount of any cash distribution received on the same entry as the plan/account description.
If no distribution was received, leave the income type and amount blank.
Underlying assets
▪ Enter each asset held in the plan/account with a value more than $1,000 at year-end.
▪ Please consult the Public Financial Disclosure Guide https://www.oge.gov/Web/278eGuide.nsf for questions
about how to report a particular kind of underlying asset. See examples for a mutual fund and a stock below.
▪ If you are using Integrity.gov, reference the plan/account entry in the “Parent Asset” field.
▪ For each underlying asset report the income amount as “None (or less than $201).”
No Distribution
With
Distribution
#
Description
EIF
Value Income Type Income
Amount
1
IRA#l:
No
1.1 ABC Diversified Bond Fund Yes $50,001 - None ( or less
$100,000 than $201)
1.2 Xylophone Technologies NIA $1,001 - $15,000 None ( or less
Corporation (XYZ) than $201)
#
Description EIF Value Income Type Income
Amount
1 Widget Co. 401(k) No Cash $17,850
distribution
1.1
ABC Diversified Bond Fund Yes
$50,001 -
None ( or less
$100,000
than $201)
1.2
Xylophone Technologies NIA
$1,001 - $15,000
None ( or less
Corporation (XYZ) than $201)
Employer or Party City/State Status and Terms Date
Widget
Co.
Charlotte, I will continue
to
participate in this defined 5/1998
NC
contribution plan. The plan sponsor will not make
further contributions after my separation.