Form DHS Form 9035 DHS Form 9035 Notification of New Top-Screen

OMB No. 1670-0014
Expiration Date: March 31, 2013
DEPARTMENT OF HOMELAND SECURITY

NOTIFICATION OF NEW TOP-SCREEN
Contact Information Submitting Request:
1a) Is the Submitter a CVI Authorized User?
No

Yes

1b) If yes, provide CVI Authorization Number of Submitter:

CVI -

2) Name of the Submitter: (Last, First, MI)

3) Phone Number of the Submitter:

4a) CSAT Facility ID #

4b) Facility Name:

5a) Facility's Street Address:

5b) City, State, Zip Code

6) Date Submitted

Notification of New Top Screen:
7) Reason for Submission:

I am submitting a new Top Screen due to the closure of my facility.
I am submitting a new Top Screen due to sale of my facility.
This Top Screen accompanies a Request for Redetermination (please check below)
I request a redetermination due to material modification either to operations or site which has
reduced the quantity of one or more of the COI(s) since the previous submission.
I request a redetermination due to material modification either to operations or site which has
increased the quantity of one or more of the COI(s) since the previous submission.
I request a redetermination due to material modification either to operations or site which has
eliminated of at least one COI, but not all of the COI(s) since the previous submission.
I request a redetermination due to material modification either to operations or site which has
eliminated all COI(s) since the previous submission.
I request a redetermination due to material modification either to operations or site which has
added at least one COI since the previous submission.
Other:

8) Explanation for Submission:

9) Desired Outcome for
Request:

For questions and assistance, please call the CSAT help desk at 1-866-323-2957
Monday - Friday 7:00a.m. - 7:00p.m., Eastern Time
Not open on federal holidays

DHS Form 9035 (4/09)

OMB No. 1670-0014
Expiration Date: March 31, 2013
NOTIFICIATION FOR NEW TOP SCREEN FORM INSTRUCTIONS

DHS FORM 9035, NOTIFICIATION FOR NEW TOP SCREEN
(Read the following instructions carefully before you complete this form.)

GENERAL:
This form should be used when a covered facility needs to submit a new top screen due to change from
the previous submission. A facility has 60 days after the sale/transfer of ownership and/or material modification to resubmit
a new Top Screen.
1.

Indicate the CSAT submitter's CVI number on the form. If you do not know if the submitter is a CVI
Authorized User, please contact the help desk for assistance.

2.

Please provide the name of the CSAT submitter. This name should be the name submitted during the
registration process.

3.

Please provide a phone number where the CSAT submitter can be reached at. When providing the phone
number, only input numeral digits into the given space. This number should the be number submitted during
the registration process.

4.

Please provide the name of the facility and the CSAT facility's ID number. If you do not know the
CSAT facilities ID number, please contact the help desk.

5.

Please provide the full physical address of the covered facility.

6.

Please enter the date this form is being submitted.

7.

Please check the box that best explains the reason for this submission.

8.

Please provide a detailed description of the reasons for this notification for a new Top-Screen.

9.

Please provide a detailed description of the desired outcome for this request.

WHEN TO FILE: In accordance to 6 CFR Part 27.210, a facility is required to file this form when a facility closes, sells,
adds new COI, deletes existing COI or changes the amount of COI. Tier 1 and Tier 2 covered facilities must complete
and submit a new top screen no less than 2 years, and no more than two years and 60 calendar days. Tier 3 and Tier 4
covered facilities must complete and submit a top screen no less than 3 years and no more than 3 years and 60
calendar
days.
WHERE TO FILE: DHS Form 9035 for Notification for New Top-Screen may be submitted to DHS.through the
Chemical Security Assessment Tool (CSAT). Keep a copy of the completed form for your records.

PRIVACY NOTICE
Authority: Section 550 of the Department of Homeland Security Appropriations Act of 2007, Pub. L. No. 109-295 and
implementing regulations, the Chemical Facility Anti-Terrorism Standards, 6 C.F.R. Part 27 authorize the collection of this
information.
Purpose: The primary purpose of this collection is to obtain information regarding a facility's request, including the submitter's
contact information.
Routine Uses: This information will be used by and disclosed to DHS personnel, contractors, or other agents to assist in
fulfilling the request and contacting the submitter, if necessary.
Disclosure: Providing this information is voluntary. If you choose not to provide this information, then DHS may not be able to
fulfill the request or contact you.

OMB 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 1670-0014. The
time required to complete this information collection is estimated to average 15 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.
DHS Form 9035 (4/09)