Form DHS Form 9036 DHS Form 9036 REQUEST FOR AN EXTENSION

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

REQUEST FOR AN EXTENSION
Contact Information Submitting Request:
1a) Is The Submitter a CVI Authorized User?
No

Yes

1b) If yes, provide CVI Authorization Number of the 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

Extension Request for:
6) Which CFATS submission request is an extension being requested for? (please check one):

Top-Screen
Security Vulnerability Assessment
Site Security Plan
7) Reason for Request:

I request the Assistant Secretary to modify the schedule due to the operations at the facility.
I request the Assistant Secretary to modify the schedule due to nature of the covered facility's vulnerabilities.
I request the Assistant Secretary to modify the schedule due to the level of security risk.
I request the Assistant Secretary to modify the schedule due to the immediacy of security risk.
Other:

8) Justification for Request

9) Proposed Due

10) Purpose of the
Request

11) Desired Outcome of
the Request

DHS Form 9036 (4/09)

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

REQUEST FOR EXTENSION FORM INSTRUCTIONS

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

DHS FORM 9036, REQUEST FOR AN EXTENSION
(Read the following instructions carefully before you complete this form.)

GENERAL: This form should be used by the submitter of record for a covered facility to request an extension for a submission
requested under 6 CFR 210.

1.

Indicate the 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 submitter. This name should be the name submitted during the registration process.

3.

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

6.

Please enter the date this form is being submitted.

7.

Please check the box of which CFATS submission request is an extension being requested for.

8.

Please provide a justification for this request.

9.

Please enter the new proposed due date.

10.

Please provide a purpose for the request.

11.

Please specify the desired outcome for the request.

WHEN TO FILE: When a facility would like to request the submission requirements outlined in 6 CFR Part
27.210 (c), to be modified.
WHERE TO FILE: DHS Form 9036 for Requesting an Extension 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 9036, Request an Extension 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 Request for an Extension 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 9036 (4/09)