Form DHS Form 9002.4 DHS Form 9002.4 Chemical Security Assessment Tool (CSAT) Transfer Respon

OMB No. 1670-0007
Expiration Date: May 31, 2011
DEPARTMENT OF HOMELAND SECURITY

Chemical Security Assessment Tool (CSAT)
Transfer Responsibility Form
Please read the instructions carefully before completing this form. The instructions must be available during
completion of this form.
Section A: Current User Information
1. User Name
1b. Last Name

1a. First Name

2. CSAT User Name

4. User Role:

Preparer

1c. Middle Initial

3. CVI Authorized User Number

Submitter

Authorizer

Other

5. User Mailing Address Information
5b. City

5a. Mailing Address

5c. State

5d. Zip Code

6. User Contact Information
6a. Phone Number

6b. Phone Extension

7. Email Address

Section B: Transfer to an Existing CSAT User/New CSAT User
8. Transfer to an Existing CSAT User
10. User Role:

Preparer

Submitter

9. Transfer to a New CSAT User
Authorizer

Other
12. CVI Authorized User Number

11. CSAT User Number

Section C: Consolidation of User Accounts
#1
#2
#3
#4
#5

DHS Form 9002.4 (9/09)

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

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OMB No. 1670-0007
Expiration Date: May 31, 2011

Section D: New User Information
13. User Name
13b. Last Name

13a. First Name

13c. Middle Initial

14. New User Mailing Address Information
14b. City

14a. Mailing Address

14c. State

14d. Zip Code

15. New User Contact Information
15a. Phone Number

15b. Phone Extension

16. Email Address

17. Is the new user a U.S. Citizen?
18. Is the new user an Officer of the Corporation or an employee designated by the Officer of the Corporation?
19. Is the new user domiciled in the U.S.?

Section E: Signatures
21a. New User Name

21b. New User Signature

21c. Date

22a. Authorizer Name

22b. Authorizer Signature

22c. Date

23a. Authorizer CSAT User Name

23b. Authorizer CVI User Number

23c. Date

DHS Form 9002.4 (9/09)

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

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OMB No. 1670-0007
Expiration Date: May 31, 2011

PRIVACY ACT STATEMENT
1.

Authority: Section 550 (c) of Public Law 109-295 and implementing regulations, 6 CFR Part 27.

2.

Purpose: This form will be used to transfer an existing CSAT user 's responsibilities to new or existing CSAT
user.

3.

Routine Uses: The Personal Identifiable Information will be used by and disclosed pursuant to a published Privacy

Act System of Records Notice. CFATS PII is collected under the General Information Technology Access Account
Records System (GITAARS) http://edocket.access.gpo.gov/2008/E8-10895.htm DHS/ALL-004
4.

Disclosure: Furnishing this information is required pursuant to Section 550 (c) of Public Law 109-295 and
implementing regulations, 6 CFR Part 27.

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 1670-0007.

INSTRUCTIONS
The instructions for completing this form can be found in the CSAT User Registration User Guide. The User Guide is
available at www.dhs.gov/chemicalsecurity.

DHS Form 9002.4 (9/09)

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

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