Form DHS Form 9035 DHS Form 9035 NOTIFICATION OF NEW TOP-SCREEN

OMB No. 1670-NEW
Expiration Date: XX/XX/XX
DEPARTMENT OF HOMELAND SECURITY

NOTIFICATION OF NEW TOP-SCREEN
Contact Information Submitting Request:
1a) Is the Submitter a CVI Authorized User?
No

Yes

1b) If yes, provide CVI Authorization Number of Submitter:

CVI -

2) Name of the Submitter: (Last, First, MI)

3) Phone Number of the Submitter:

4a) CSAT Facility ID #

4b) Facility Name:

5a) Facility's Street Address:

5b) City, State, Zip Code

6) Date Submitted

Notification of New Top-Screen:
7) Reason for Submission:

I am submitting a new Top-Screen due to the closure of my facility.
I am submitting a new Top-Screen due to sale of my facility.
This Top-Screen accompanies a Request for Redetermination (please check below)
I request a redetermination due to material modification either to operations or site which has
reduced the quantity of one or more of the COI(s) since the previous submission.
I request a redetermination due to material modification either to operations or site which has
increased the quantity of one or more of the COI(s) since the previous submission.
I request a redetermination due to material modification either to operations or site which has
eliminated of at least one COI, but not all of the COI(s) since the previous submission.
I request a redetermination due to material modification either to operations or site which has
eliminated all COI(s) since the previous submission.
I request a redetermination due to material modification either to operations or site which has
added at least one COI since the previous submission.
Other:

8) Explanation for Submission:

9) Desired Outcome for
Request:

For questions and assistance, please call the CFATS Helpdesk at 1-866-323-2957
Monday - Friday 7:00a.m. - 7:00p.m., Eastern Time
Not open on federal holidays

DHS Form 9035 (4/09)

NOTIFICIATION FOR NEW TOP-SCREEN FORM INSTRUCTIONS

OMB No. 1670-NEW
Expiration Date: XX/XX/XX

DHS FORM 9035, NOTIFICIATION FOR NEW TOP-SCREEN
(Read the following instructions carefully before you complete this form.)

GENERAL:
This form should be used when a covered facility needs to submit a new Top-Screen due to change from
the previous submission. A facility has 60 days after the sale/transfer of ownership and/or material modification to resubmit
a new Top Screen.
1.

Indicate the CSAT submitter's CVI number on the form. If you do not know if the submitter is a CVI
Authorized User, please contact the help desk for assistance.

2.

Please provide the name of the CSAT submitter. This name should be the name submitted during the
registration process.

3.

Please provide a phone number where the CSAT submitter can be reached at. When providing the phone
number, only input numeral digits into the given space. This number should the be number submitted during
the registration process.

4.

Please provide the name of the facility and the CSAT facility's ID number. If you do not know the
CSAT facilities ID number, please contact the help desk.

5.

Please provide the full physical address of the covered facility.

6.

Please enter the date this form is being submitted.

7.

Please check the box that best explains the reason for this submission.

8.

Please provide a detailed description of the reasons for this notification for a new Top-Screen.

9.

Please provide a detailed description of the desired outcome for this request.

WHEN TO FILE: In accordance to 6 CFR Part 27.210, a facility is required to file this form when a facility closes, sells,
adds new COI, deletes existing COI or changes the amount of COI. Tier 1 and Tier 2 covered facilities must complete
and submit a new top screen no less than 2 years, and no more than two years and 60 calendar days. Tier 3 and Tier 4
covered facilities must complete and submit a top screen no less than 3 years and no more than 3 years and 60
calendar
WHERE TO FILE: DHS Form 9035 for Notification for New Top-Screen may be submitted to DHS.through the
Chemical Security Assessment Tool (CSAT). Keep a copy of the completed form for your records.

PRIVACY ACT STATEMENT
1.

FORM/TITLE: Department of Homeland Security (DHS) DHS Form 9035, Notification for New Top-Screen with
the Department of Homeland Security.

2.

AUTHORITY: Section 550 (c) of Public Law 109-295 entitled, Making Appropriations of the Department of
Homeland Security for the Fiscal Year Ending September 30, 2007, and for other purposes (October 4, 2006),
directs DHS to protect from public disclosure "information developed under [Section 550], including vulnerability
assessments... and other security related information records and documents..." As required by Section 550,
DHS Promulgated CFATS as an interim final rule in April 2007. See 6 CFR Part 27; 72 Fed. Reg. 17688

3.

BURDEN STATEMENT: The public reporting burden for the Notification for New Top-Screen is estimated to be
15 minutes. The burden estimate includes time for reviewing instructions, researching the situation, gathering and
maintaining the needed data, and completing and submitting the form. You may send comments regarding the
accuracy of the burden estimate and any suggestions for reducing the burden to:
NPPD / IP / Infrastructure Security Compliance Division
Attention: CFATS Project Manager
U.S. Department of Homeland Security
Mail Stop 8100
Washington, DC 20528-8100

PAPERWORK REDUCTION ACT STATEMENT
In accordance with the Paperwork Reduction Act, no one is required to respond to a collection of information unless it
displays a valid OMB Control Number. The valid OMB Control Number for this information collection is 1670-NEW. The
time required to complete this information collection is estimated to average 15 minutes per response, including the
time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and
completing and reviewing the collection of information.
DHS Form 9035 (4/09)