United States House of Representatives

Committee on Standards of Official Conduct

Statement of Recusal

1. This is to notify the Committee that, pursuant to House Rule XXVII, I have recused myself
from any official matter that would affect the following private entity as a result of my
negotiation or agreement regarding future employment or compensation:

effective as of

,200 .

2. Pursuant to this rule, I am required to recuse myself from participation in any official matter
that will present a conflict of interest or give the appearance thereof.

3. I will promptly inform the Committee in writing if I withdraw my recusal statement.

4. For Members only: I have provided to the Clerk for public disclosure a copy of my
completed Notification of Negotiations or Agreement for Future Employment form regarding
this entity.

Signature:

Print Name:

Date:

For staff, name of employing Member/committee:

Submit ORIGINAL to: Committee on Standards of Official Conduct

HT-2, The Capitol
NOTE: Forms may not be filed by fax.