Form DHS Form 9037 DHS Form 9037 Request for Determination

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

REQUEST FOR REDETERMINATION
Contact Information Submitting Request:
1a) Is the Submitter a CVI Authorized User?
Yes

No

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:

Redetermination Request:
7) Reason for Request:

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 Request:

9) Desired Outcome for
Request:

DHS Form 9037 (4/09)

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

OMB No. 1670-0014
Expiration Date: March 31, 2013
REQUEST FOR REDETERMINATION FORM INSTRUCTIONS

DHS FORM 9037, REQUEST FOR REDETERMINATION
(Read the following instructions carefully before you complete this form.)

GENERAL:
This form should be completed by the submitter of record of a covered facility that has materially altered
its operations to seek redetermination.
1.

Indicate the 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 submitter. This name should be the name submitted during the registration
process.

3.

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

7.

Please check the box that best describes the reason for this redetermination request.

8.

Please provide a detailed description of the reasons for this request for redetermination. (i.e., propane STQ)

9.

Please provide a detailed description of the desired outcome for this request. (i.e., tiering level)

WHEN TO FILE: In accordance to 6 CFR Part 27.210 (d), if a facility previously determined to present a high level of
security risk has made material modifications to its operations, it must submit this form and a request is within 60 days.
WHERE TO FILE: DHS Form 9037 for Requesting a Redetermination 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 9037 (4/09)