E-Verify Program Data Collection

DEPARTMENT OF HOMELAND SECURITY

NON-DISCLOSURE AGREEMENT
I, _______________________________________, an individual official, employee, consultant, or subcontractor of or to
_____________________ (the Authorized Entity), intending to be legally bound, hereby consent to the terms in this
Agreement in consideration of my being granted conditional access to certain information, specified below, that is owned
by, produced by, or in the possession of the United States Government.
(Signer will acknowledge the category or categories of information that he or she may have access to, and the signer’s willingness to comply with
the standards for protection by placing his or her initials in front of the applicable category or categories.)
Initials:

Protected Critical Infrastructure Information (PCII)

I attest that I am familiar with, and I will comply with all requirements of the PCII program set out in the Critical
Infrastructure Information Act of 2002 (CII Act) (Title II, Subtitle B, of the Homeland Security Act of 2002, Public Law
107-296, 196 Stat. 2135, 6 USC 101 et seq.), as amended, the implementing regulations thereto (6 CFR Part 29), as
amended, and the applicable PCII Procedures Manual, as amended, and with any such requirements that may be
officially communicated to me by the PCII Program Manager or the PCII Program Manager’s designee.
Initials:

Sensitive Security Information (SSI)

I attest that I am familiar with, and I will comply with the standards for access, dissemination, handling, and
safeguarding of SSI information as cited in this Agreement and in accordance with 49 CFR Part 1520, “Protection of
Sensitive Security Information,” “Policies and Procedures for Safeguarding and Control of SSI,” as amended, and any
supplementary guidance issued by an authorized official of the Department of Homeland Security.
Initials:

Other Sensitive but Unclassified (SBU)

As used in this Agreement, sensitive but unclassified information is an over-arching term that covers any information,
not otherwise indicated above, which the loss of, misuse of, or unauthorized access to or modification of could adversely
affect the national interest or the conduct of Federal programs, or the privacy to which individuals are entitled under
Section 552a of Title 5, as amended, but which has not been specifically authorized under criteria established by an
Executive Order or an Act of Congress to be kept secret in the interest of national defense or foreign policy. This
includes information categorized by DHS or other government agencies as: For Official Use Only (FOUO); Official Use
Only (OUO); Sensitive Homeland Security Information (SHSI); Limited Official Use (LOU); Law Enforcement
Sensitive (LES); Safeguarding Information (SGI); Unclassified Controlled Nuclear Information (UCNI); and any
other identifier used by other government agencies to categorize information as sensitive but unclassified.
I attest that I am familiar with, and I will comply with the standards for access, dissemination, handling, and
safeguarding of the information to which I am granted access as cited in this Agreement and in accordance with the
guidance provided to me relative to the specific category of information.
I understand and agree to the following terms and conditions of my access to the information indicated above:
1. I hereby acknowledge that I have received a security indoctrination concerning the nature and protection of information to which I
have been provided conditional access, including the procedures to be followed in ascertaining whether other persons to whom I
contemplate disclosing this information have been approved for access to it, and that I understand these procedures.
2. By being granted conditional access to the information indicated above, the United States Government has placed special
confidence and trust in me and I am obligated to protect this information from unauthorized disclosure, in accordance with the
terms of this Agreement and the laws, regulations, and directives applicable to the specifi c categories of information to which I am
granted access.
3. I attest that I understand my responsibilities and that I am familiar with and will comply with the standards for protecting such
information that I may have access to in accordance with the terms of this Agreement and the laws, regulations, and/or directives
applicable to the specifi c categories of information to which I am granted access. I understand that the United States Government
may conduct inspections, at any time or place, for the purpose of ensuring compliance with the conditions for access, dissemination,
handling and safeguarding information under this Agreement.
DHS Form 11000-6 (08-04)

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4. I will not disclose or release any information provided to me pursuant to this Agreement without proper authority
or authorization. Should situations arise that warrant the disclosure or release of such information I will do so
only under approved circumstances and in accordance with the laws, regulations, or directives applicable to
the specific categories of information. I will honor and comply with any and all dissemination restrictions cited or verbally
relayed to me by the proper authority.
5. (a) For PCII - (1) Upon the completion of my engagement as an employee, consultant, or subcontractor under
the contract, or the completion of my work on the PCII Program, whichever occurs first, I will surrender promptly
to the PCII Program Manager or his designee, or to the appropriate PCII officer, PCII of any type whatsoever
that is in my possession.
(2) If the Authorized Entity is a United States Government contractor performing services in support of the PCII Program, I
will not request, obtain, maintain, or use PCII unless the PCII Program Manager or Program Manager’s designee
has first made in writing, with respect to the contractor, the certification as provided for in Section 29.8(c) of the
implementing regulations to the CII Act, as amended.
(b) For SSI and SBU - I hereby agree that material which I have in my possession and containing information covered by
this Agreement, will be handled and safeguarded in a manner that affords sufficient protection to prevent the unauthorized
disclosure of or inadvertent access to such information, consistent with the laws, regulations, or directives applicable to the
specific categories of information. I agree that I shall return all information to which I have had access or which is in my
possession 1) upon demand by an authorized individual; and/or 2) upon the conclusion of my duties, association, or support
to DHS; and/or 3) upon the determination that my official duties do not require further access to such information.
6. I hereby agree that I will not alter or remove markings, which indicate a category of information or require specific
handling instructions, from any material I may come in contact with, in the case of SSI or SBU, unless such alteration or
removal is consistent with the requirements set forth in the laws, regulations, or directives applicable to the specific
category of information or, in the case of PCII, unless such alteration or removal is authorized by the PCII Program
Manager or the PCII Program Manager’s designee. I agree that if I use information from a sensitive document or other
medium, I will carry forward any markings or other required restrictions to derivative products, and will protect them in
the same matter as the original.
7. I hereby agree that I shall promptly report to the appropriate official, in accordance with the guidance issued for
the applicable category of information, any loss, theft, misuse, misplacement, unauthorized disclosure, or other security
violation, I have knowledge of and whether or not I am personally involved. I also understand that my anonymity will be
kept to the extent possible when reporting security violations.
8. If I violate the terms and conditions of this Agreement, such violation may result in the cancellation of my conditional
access to the information covered by this Agreement. This may serve as a basis for denying me conditional access to other
types of information, to include classified national security information.
9. (a) With respect to SSI and SBU, I hereby assign to the United States Government all royalties, remunerations, and
emoluments that have resulted, will result, or may result from any disclosure, publication, or revelation of the information
not consistent with the terms of this Agreement.
(b) With respect to PCII I hereby assign to the entity owning the PCII and the United States Government, all
royalties, remunerations, and emoluments that have resulted, will result, or may result from any disclosure,
publication, or revelation of PCII not consistent with the terms of this Agreement.
10. This Agreement is made and intended for the benefit of the United States Government and may be enforced by the
United States Government or the Authorized Entity. By granting me conditional access to information in this context, the
United States Government and, with respect to PCII, the Authorized Entity, may seek any remedy available to it to enforce
this Agreement including, but not limited to, application for a court order prohibiting disclosure of information in breach of
this Agreement. I understand that if I violate the terms and conditions of this Agreement, I could be subjected to
administrative, disciplinary, civil, or criminal action, as appropriate, under the laws, regulations, or directives applicable to
the category of information involved and neither the United States Government nor the Authorized Entity have waived any
statutory or common law evidentiary privileges or protections that they may assert in any administrative or court proceeding
to protect any sensitive information to which I have been given conditional access under the terms of this Agreement.

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11. Unless and until I am released in writing by an authorized representative of the Department of Homeland Security (if
permissible for the particular category of information), I understand that all conditions and obligations imposed upon me by
this Agreement apply during the time that I am granted conditional access, and at all times thereafter.
12. Each provision of this Agreement is severable. If a court should find any provision of this Agreement to be
unenforceable, all other provisions shall remain in full force and effect.
13. My execution of this Agreement shall not nullify or affect in any manner any other secrecy or non-disclosure
Agreement which I have executed or may execute with the United States Government or any of its departments or
agencies.
14. These restrictions are consistent with and do not supersede, conflict with, or otherwise alter the employee
obligations, rights, or liabilities created by Executive Order No. 12958, as amended; Section 7211 of Title 5, United
States Code (governing disclosures to Congress); Section 1034 of Title 10, United States Code, as amended by the
Military Whistleblower Protection Act (governing disclosure to Congress by members of the military); Section
2302(b)(8) of Title 5, United States Code, as amended by the Whistleblower Protection Act (governing disclosures of
illegality, waste, fraud, abuse or public health or safety threats); the Intelligence Identities Protection Act of 1982 (50
USC 421 et seq.) (governing disclosures that could expose confidential Government agents); and the statutes which
protect against disclosure that may compromise the national security, including Sections 641, 793, 794, 798, and 952
of Title 18, United States Code, and Section 4(b) of the Subversive Activities Act of 1950 (50 USC 783(b)). The
definitions, requirements, obligations, rights, sanctions, and liabilities created by said Executive Order and listed
statutes are incorporated into this agreement and are controlling.
15. Signing this Agreement does not bar disclosures to Congress or to an authorized official of an executive agency
or the Department of Justice that are essential to reporting a substantial violation of law.
16. I represent and warrant that I have the authority to enter into this Agreement.
17. I have read this Agreement carefully and my questions, if any, have been answered. I acknowledge that the
briefing officer has made available to me any laws, regulations, or directives referenced in this document so that I
may read them at this time, if I so choose.
DEPARTMENT OF HOMELAND SECURITY

NON-DISCLOSURE AGREEMENT
Acknowledgement
Typed/Printed Name:

Government/Department/Agency/Business Address

Telephone Number:

I make this Agreement in good faith, without mental reservation or purpose of evasion.
Signature:

WITNESS:
Typed/Printed Name:

Government/Department/Agency/Business Address

Telephone Number:

Signature:

This form is not subject to the requirements of P.L. 104-13, “Paperwork Reduction Act of 1995” 44 USC, Chapter 35.
DHS Form 11000-6 (08-04)

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