DOE F 5631.29 Security Termination Statement

Non Fillable
DOE F 5631.29
(10/92)

OMB Control No.
1910-1800
OMB Burden
Disclosure Statement
below

All Other Editions Are Obsolete

(Facility or Installation Where Terminated)

U.S. Department of Energy

SECURITY TERMINATION STATEMENT
NAME AND TITLE (Print all blocks)

EMPLOYER YOU ARE LEAVING

FUTURE RESIDENCE

NAME AND ADDRESS OF FUTURE EMPLOYER

REASON FOR TERMINATION
SOCIAL SECURITY NUMBER

DATE OF BIRTH

DATE OF TERMINATION

DOE NUMBER (IF KNOWN)

I make the following statement in connection with the forthcoming termination of my access authorization
(security clearance) granted by the U.S. Department of Energy (DOE).
1. In accordance with DOE security regulations, I have destroyed or transferred to persons designated
by the DOE all classified documents and material for which I was charged or which I had in my
possession.
2. I have returned to a DOE official or person acting for the DOE all security badges, credentials, or
other identification or access media issued to me by the DOE or its contractors.
3. I will not reveal to any person any Restricted Data, Formerly Restricted Data, or other classified
information of which I have gained knowledge except as authorized by law, regulations of the DOE, or in
writing by officials of the DOE empowered to grant permission for such disclosure.
4. I will immediately report to the Federal Bureau of Investigation (FBI) any attempt by an unauthorized
individual to acquire classified information from me.
5. I am aware that the Atomic Energy Act of 1954 and U.S. Code, Title 18 ‘‘Crimes and Criminal
Procedures,’’ prescribe penalties for unauthorized disclosure of Restricted Data, Formerly Restricted
Data, and other information relating to the national defense.
6. I am aware that I may be subject to criminal penalties if I have made any statement of material facts
knowing that such statement is false or if I willfully conceal any material fact (Title 18, U.S. Code,
Section 1001).

(Signature of Person Conducting Interview)

(Signature of Person Whose Access
Authorization is Being Terminated)

(Title of Position)

(Date)
See Reverse for Privacy Act Statement.

DOE F 5631.29
(10/92)

OMB Control No.
1910-1800

All Other Editions Are Obsolete

PRIVACY ACT STATEMENT
Collection of the information requested is authorized by the Atomic Energy Act of 1954, as amended, and by
Executive Orders 10450, 10865, and 12356.
Disclosure of the information on this form is voluntary; however, your decision not to complete this form could result
in a delay in processing any future request for reinstatement of your U.S. Department of Energy (DOE) access
authorization (security clearance). Your DOE access authorization can be terminated regardless of whether this
form is completed. Your name, Social Security Number, and date of birth are used as identifying factors to establish
and maintain records of DOE access authorization actions in the DOE System of Records, DOE-42, ‘‘Personnel
Security Clearance Index,’’ and this form will be maintained in your DOE Personnel Security File (DOE System of
Records, DOE-43, ‘‘Personnel Security Clearance Files’’). Access to these records is permitted as stipulated in DOE
5631.2, ‘‘Personnel Security Program,’’ and as listed in Routine Uses in Appendix B to the DOE System of Records.

OMB BURDEN DISCLOSURE STATEMENT
Public reporting burden for this collection of information is estimated to average 5 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. Send comments regarding this burden estimate or any other
aspect of this collection of information, including suggestions for reducing this burden, to Office of Information
Resources Management, AD-241.2 - GTN, Paperwork Reduction Project (1910-1800), U.S. Department of Energy,
1000 Independence Avenue, S.W., Washington D.C. 20585; and to the Office of Management and Budget,
Paperwork Reduction Project (1910-1800), Washington, D.C. 20503.