DHS Form 9002.6

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

Chemical Security Assessment Tool (CSAT)
Transfer Responsibility from an Absentee Authorizer
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 Authorizer
3. CSAT Username

4. CVI Authorized User Number

6a. First Name

5. Individual Authorizing Transfer

6b. Last Name

6c. Middle Initial

7. Is this individual a U.S. Citizen?

Yes

No

8. Was the individual an Officer of the Corporation or designated by an Officer of the Corporation?

Yes

No

9. Is the individual domiciled in the U.S.?

Yes

No

Section C: New Authorizer Information
10. CSAT Username

11. CVI Authorized User Number

12b. Last Name

12a. First Name

13a. Mailing Address

13b. City

14a. Phone Number

14b. Phone Extension

12c. Middle Initial

13c. State

13d. Zip Code

14. Email Address

15. Is this individual a U.S. Citizen?

Yes

No

16. Is the user an Officer of the Corporation or designated by an Officer of the Corporation?

Yes

No

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

Yes

No

Section D: Signatures
18a. User Name

18b.User Signature

18c. Date

19a. Authorizer Name

19b. Authorizer Signature

19c. Date

20a. Authorizer CSAT User Name

20b. Authorizer CVI User Number

20c. Date

DHS Form 9002.6 (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 transfers an existing authorizer user account for an absentee authorizer to a new user. If the
new authorizer is a new CSAT user please complete sections A through D. If the new authorizer is an existing
CSAT user please complete sections A, B and D.

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 9002.6 (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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