EFTA01125764.pdf

SENSITIVE COMPARTMENTED INFORMATION NONDISCLOSURE STATEMENT PRIVACY ACT STATEMENT AUTHORITY: EO 9397, November 1943 (SSN). PRINCIPAL PURPOSE(SI: The information contained herein will be used to precisely identify individuals when it is necessary to certify their access to sensitive compartmented information. ROUTINE USE(S): Blanket routine uses, as published by Defense Intelligence Agency in the Federal Register. DISCLOSURE: Voluntary; however, failure to provide requested information may result in delaying the processing of your certification. SECTION A An Agreement Between and the United States. (Printed or Typed Name) 1. Intending to be legally bound. I hereby accept the obligations 4. (Continued) have reason to believe are derived from SCI, contained in this Agreement in consideration of my being granted that I contemplate disclosing to any person not authorized to have access to information or material protected within Special Access access to SCI or that I have prepared for public disclosure. I Programs, hereinafter referred to in this Agreement as Sensitive understand and agree that my obligation to submit such preparations Compartmented Information (SCI). I have been advised that SCI for review applies during the course of my access to SCI and involves or derives from intelligence sources or methods and is thereafter, and I agree to make any required submissions prior to classified or in the process of a classification determination under the discussing the preparation with, or showing it to, anyone who is not standards of Executive Order 12356 or other Executive order or authorized to have access to SCI. I further agree that I will not statute. I understand and accept that by being granted access to SCI, disclose the contents of such preparation to any person not special confidence and trust shall be placed in me by the United States authorized to have access to SCI until I have received written Government. authorization from the Department or Agency that last authorized my access to SCI that such disclosure is permitted. 2. I hereby acknowledge that I have received a security indoctrination concerning the nature and protection of SCI. including 5. I understand that the purpose of the review described in the procedures to be followed in ascertaining whether other persons to paragraph 4 is to give the United States a reasonable opportunity to whom I contemplate disclosing this information have been approved determine whether the preparation submitted pursuant to paragraph for access to it, and I understand these procedures. I understand that I 4 set forth any SCI. I further understand that the Department or may be required to sign subsequent agreements upon being granted Agency to which I have made a submission will act upon them, access to different categories of SCI. I further understand that all my coordinating within the Intelligence Community when appropriate, obligations under this Agreement continue to exist whether or not I and make a response to me within a reasonable time, not to exceed am required to sign such subsequent agreements. 30 working days from date of receipt. 3. I have been advised that unauthorized disclosure, unauthorized 6. I have been advised that any breach of this Agreement may retention, or negligent handling of SCI by me could cause irreparable result in the termination of my access to SCI and removal from a injury to the United States or be used to advantage by a foreign position of special confidence and trust requiring such access, as nation. I hereby agree that I will never divulge anything marked as well as the termination of my employment or other relationships SCI or that I know to be SCI to anyone who is not authorized to with any Department or Agency that provides me with access to receive it without prior written authorization from the United States SCI. In addition. I have been advised that any unauthorized Government department or agency (hereinafter Department or disclosure of SCI by me may constitute violations of United States Agency) that last authorized my access to SCI. I understand that it is criminal laws, including the provisions of Sections 793, 794, 798, my responsibility to consult with appropriate management authorities and 952, Title IS, United States Code, and of Section 783(b), Tide in the Department or Agency that last authorized my access to SCI, 50, United States Code. Nothing in this Agreement constitutes a whether or not I am still employed by or associated with that waiver by the United States of the right to prosecute me for any Department or Agency or a contractor thereof, in order to ensure that statutory violation. I know whether information or material within my knowledge or control that I have reason to believe might be SCI, or related to or 7. I understand that the United States Government may seek derived from SCI, is considered by such Department or Agency to be any remedy available to it to enforce this Agreement, including, but SCI. I further understand that I am also obligated by law and not limited to. application for a court order prohibiting disclosure of regulation not to disclose any classified information or material in an information in breach of this Agreement. I have been advised that unauthorized fashion. the action can be brought against me in any of the several appropriate United States District Courts where the United States 4. In consideration of being granted access to SCI and of being Government may elect to file the action. Court costs and reasonable assigned or retained in a position of special confidence and trust attorneys' fees incurred by the United States Government may be requiring access to SCI, I hereby agree to submit for security review assessed against me if I lose such action. by the Department or Agency that last authorized my access to such information or material, any writing or other preparation in any form, 8. I understand that all information to which I may obtain including a work of fiction, that contains or purports to contain any access by signing this Agreement is now and will remain the SCI or description of activities that produce or relate to SCI or that I property of the United States Government unless and until otherwise determined by an appropriate official or final ruling of a DD FORM 1847-1, DEC 91 PREVIOUS EDITIONS ARE OBSOLETE. Adobe Professional 8.0 EFTA01125764  8. (Continued) court of law. Subject to such determination, I II. (Continued) (governing disclosures of illegality, waste, fraud, do not now, nor will I ever, possess any right, interest, title or abuse or public health or safety threats); the Intelligence Identities claim whatsoever to such information. I agree that I shall return all Protection Act of 1982 (50 USC 421 et seq.) (governing disclosures materials that may have come into my possession or for which I am that could expose confidential Government agents), and the statutes responsible because of such access, upon demand by an authorized which protect against disclosure that may compromise the national representative of the United States Government or upon the security, including Section 641, 793, 794, 798, and 952 of Title IS, conclusion of my employment or other relationship with the United States Government entity providing me access to such materials. If United States Code, and Section 4(b) of the Subversive Activities Act I do not return such materials upon request, I understand this may of 1950 (50 USC Section 783(b)). The definitions, requirements, be a violation of Section 793, Title 18, United States Code. obligations, rights, sanctions and liabilities created by said Executive Order and listed statutes are incorporated into this agreement and are 9. Unless and until I am released in writing by an authorized controlling. representative of the Department or Agency that last provided me with access to SCI, I understand that all the conditions and 12. I have read this Agreement carefully and my questions, if any, obligations imposed upon me by this Agreement apply during the have been answered to my satisfaction. I acknowledge that the time I am granted access to SCI, and at all times thereafter. briefing officer has made available Sections 793, 794, 798, and 952 of 10. Each provision of this Agreement is severable. If a court Title IS, United States Code, and Section 783(6) of Title 50, United should find any provision of this Agreement to be unenforceable, all States Code, and Executive Order 123%, as amended, so that I may other provisions of this Agreement shall remain in full force and read them at this time, if I so choose. effect. This Agreement concerns SCI and does not set forth such other conditions and obligations not related to SCI as may now or 13. I hereby assign to the United States Government all rights, title hereafter pertain to my employment by or assignment or relationship and interest, and all royalties, remunerations, and emoluments that with the Department or Agency. have resulted, will result, or may result from any disclosure, publication, or revelation not consistent with the terms of this II. These restrictions are consistent with and do not supersede Agreement. conflict with or otherwise alter the employee obligations, rights, or liabilities created by Executive Order 12356; Section 7211 of Title 5, United States Code (governing disclosures to Congress); Section 14. This Agreement shall be interpreted under and in conformance 1034 of Title 10, United States Code, as amended by the Military with the laws of the United States. Whistleblower Protection Act (governing disclosure to Congress by members of the military); Section 2302(6)(8) of Title 5, United I5. I make this Agreement without any mental reservation or States Code, as amended by the Whistleblower Protection Act purpose of evasion. 16. TYPED OR PRINTED NAME (Last, First, Middle Initial, 17. GRADE/RANK/SVC 18. SOCIAL SECURITY NO. 19. BILLET NO. (Optional) 20. ORGANIZATION 21. SIGNATURE 22. DATE SIGNED fYYMMOD, FOR USE BY MILITARY AND GOVERNMENT CIVILIAN PERSONNEL SECTION B The execution of this Agreement was witnessed by the undersigned, who accepted it on behalf of the United States Government as a prior condition of access to Sensitive Compartmented Information. 23. TYPED OR PRINTED NAME (Last, First, Middle Initial) 24. ORGANIZATION 25. SIGNATURE 26. DATE SIGNED YYMMDD FOR USE BY CONTRACTORS/CONSULTANTS/NON-GOVERNMENT PERSONNEL SECTION C The execution of this Agreement was witnessed by the undersigned. 27. TYPED OR PRINTED NAME (Last, First, Middle Initial) 28. ORGANIZATION 29. SIGNATURE 30. DATE SIGNED YYMMDD SECTION D This Agreement was accepted by the undersigned on behalf of the United States Government as a prior condition of access to Sensitive Compartmented Information. 31. TYPED OR PRINTED NAME (Last, First, Middle Initial) 32. ORGANIZATION 33. SIGNATURE 34. DATE SIGNED (YYMMDD) DD FORM 1847-1, DEC 91 (BACK) R;sct EFTA01125765