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Judicial Watch • State Dept Form OF109

State Dept Form OF109

State Dept Form OF109

Page 1: State Dept Form OF109

Category:

Number of Pages:1

Date Created:April 1, 1998

Date Uploaded to the Library:November 23, 2015

Tags:Form, interviewing, Restricted, typed, Sections, signature, Dept, Violation, employment, classified, officer, AGENCY, government, department, states, united, disclosure


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STATE-USIA
SEPARATION STATEMENT
(please type print)
make the following statement connection with
separation from employment the Department State the United States Information Agency. used herein, the term employment includes
all periods assignment detail, well any periods temporary, part-time intermittent employment therein, and the term separation
includes suspension for any period excess days, retirement from active duty, transfer another agency, resignation, furlough enter
military service, etc. have surrendered responsible officials all classified administratively controlled documents and material with which was charged which had possession, and not retaining possession, custody, control, documents material containing classified administratively
controlled information furnished during the course such employment developed consequence thereof, including any diaries,
memorandums conversation, other documents personal nature that contain classified administratively controlled information. have surrendered responsible officials all unclassified documents and papers relating the official business the Government acquired while the employ the Department USIA. shall not publish, nor reveal any person, any classified administratively controlled information which have knowledge, any other
information transmitted confidence the course official duties, except may authorized officials the employing
Department Agency empowered grant permission for such disclosure. have been advised the interviewing officer whose name appears below and understand the criminal penalties relating U.S. Government
records and information and the use thereof:
Title 18, U.S. Code
Section 641 Public Money, Property Records
793 Gathering, Transmitting Losing
Defense Information
794 Gathering Delivering Defense
Information Aid Foreign Govt.
798 Disclosure Classified Information
952 Diplomatic Codes and Correspondence
1905 Disclosure Confidential Information
2071 Concealment, Removal, Mutilation
Records
Title 50, U.S. Code
Section 783 (b) Communication Classified Information Government Officer Employee
783(d) Penalties for Violation
Title 42, U.S. Code
Section 2272 Violation Specific Sections
2273 Violation General Sections
2274 Communication Restricted Data
2275 Receipt Restricted Data
2276 Tampering With Restricted Data
2277 Disclosure Restricted Data
These restrictions are consistent with not supersede, conflict with otherwise alter the employee obligations, rights liabilities created
Executive Order 12356; Section 7211 Title United States Code (governing disclosures Congress); Section 1034 Title 10, United States
Code, amended the Military Whistleblower Protection Act (governing disclosures illegality, waste, fraud, abuse public health safety
threats); the Intelligence Identities Protection Act 1982 (50 U.S.C. 421 seq.) (governing disclosures that could expose confidential Government
agents); and the statutes which protect against disclosure that may compromise the national security, including Sections 641, 793, 794, 798 and
952 Title 18, United States code, and Section 4(b) the Subversive Activities Act 1950 (50 U.S.C. Section 783(b)). The definitions,
requirements, obligations, rights, sanctions and liabilities created said Executive Order and listed statutes are incorporated into this Agreement
and are controlling. reaffirm that the provisions the espionage laws, other federal criminal laws and executive orders applicable the safeguarding classified
information have been made available me; that have returned all classified information custody; that will not communicate transmit
classified information any unauthorized person organization; that will promptly report the Federal Bureau investigation any attempt
unauthorized person solicit classified information, and that (have)(have not) (strike out inappropriate word words) received security
debriefing. have been advised the interviewing officer whose signature appears below and fully understand that Section 1001 Title 18, United States
Code, provides criminal penalties for knowingly and willfully falsifying concealing material fact statement document submitted any
department agency the United States Government concerning matter under its jurisdiction.
(Signature Interviewing Officer)
(Signature Presence Interviewing Officer)
(Date)
(Date Birth)
(Typed Name Interviewing Officer)
(Date Signed)
(Post, Department Agency)
(Typed Name Employee)
(Other Names Used During This Period Employment)
STATE-USIA
OPTIONAL FORM 109
994