Enclosure (4) to COMDTINST 5370.9B
TEMPLATE RECUSAL LETTER
(Name of Filer)
(Name of Reviewing Official)
STATEMENT OF DISQUALIFICATION
1. This is to notify you that I have a personal financial interest in [insert name of company, etc.]
and that I have disqualified myself from official personal and substantial participation in any
particular matter that will have a direct and predictable affect on that personal financial interest.
2. For the purposes of this disqualification, all incoming matters will be screened to ensure that
matters involving the entity or entities identified above are not brought to my attention. A person
senior to me in the chain of command shall handle such matters without my knowledge or
participation when they cannot be handled at a level lower than mine.
3. In order to insure that I do not become involved in any matter in which I have a personal
financial interest, I hereby appoint ________________________________ as a screening agent
to review all matters coming to me and to refer any matter concerning the above-mentioned entity
or entities up the chain of command for action when appropriate.
Signature of Filer
Integrated Publishing, Inc.
9438 US Hwy 19N #311 Port Richey, FL 34668
Phone For Parts Inquiries: (727) 755-3260