DHS Form 9002.5 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 of Responsibility from an Absentee User

Please read the instructions carefully before completing this form. The instructions must be available during
completion of this form.
Section A: Facility Identification Information
1. Facility ID Number

2. Facility Name

Section B: User Information for the Absentee Individual
3. CSAT Username

4. CVI Authorized User Number

5a. First Name

5b. Last Name

5c. Middle Initial

Section C: New User Information
6. CSAT Username

7. CVI Authorized User Number

9a. Mailing Address

9b. City

10a. Phone Number

8b. Last Name

8a. First Name

8c. Middle Initial

9d. Zip Code

9c. State

10b. Phone Extension

11. Email Address

12. Is the user a U.S. Citizen?

Yes

No

13. Is the user domiciled in the U.S.?

Yes

No

Section D: Signatures
14a. User Name

14b.User Signature

14c. Date

15a. Authorizer Name

15b. Authorizer Signature

15c. Date

16a. Authorizer CSAT User Name

16b. Authorizer CVI User Number

16c. Date

DHS Form 9002.5 (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 should be used when a facility realizes that a CSAT user is absent and would like to transfer
their facility's responsibilities to a different user. The responsibilities must be transferred to an existing CSAT user.
The existing CSAT user must be a preparer or submitter.

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 9002.5 (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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