Required Protected Critical Infrastructure Information (PCII) Regulation Statements

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Express Statement
Certification Statement
Protection Statement

All information submitted for PCII protection must include:
An Express Statement requesting the protection offered by the CII Act; and
A Certification Statement including the submitter’s contact information and certifying
that the information is not customarily in the public domain.
The Express Statement and the Certification Statement must be included with all information
submitted for PCII protection. How to Submit Critical Infrastructure Information (CII) For PCII
Protection provides more details about the submission process.
All PCII is labeled with the Protection Statement by the PCII Program Office or the PCII
Program Manager Designee to help ensure the material is safeguarded and protected as PCII.
If PCII does not have the Protection Statement, please notify the PCII Program Office at [email protected] or 202-360-3023. Learn how PCII is protected.
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Express Statement
Please copy and paste the following information for your Express Statement:
This information is voluntarily submitted to the federal government in expectation of protection
from disclosure as provided by the provisions of the Critical Infrastructure Information Act of
2002.
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Certification Statement
Please copy and paste the following information for your Certification Statement. This
must be completed, signed and dated:

file:///D|/Documents%20and%20Settings/evette.maynard-noel/My%20Documents/PCII%20Regulation%20Statements%20%20Homeland%20Security.htm[7/11/2013 11:58:48 AM]

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PCII Regulation Statements | Homeland Security
To the best of my knowledge, information, and belief, the information being submitted is not
customarily in the public domain. 
I attest that I am not submitting this information in lieu of complying with a regulatory
requirement. 
I am authorized to submit this information to be considered for protection under the Critical
Infrastructure Information Act of 2002.
Affix your signature and date signed.
Submitter Name:
Submitter Title:
Organization or Company Name (if applicable):
Mailing Address:
City:
Office Telephone:
Alternate Telephone:
E-mail Address:
Alternate Contact Name:
Alternate Contact Title:
Organization or Company Name (if different from submitter):
Mailing Address:
City:
State:
Office Telephone:
Alternate Telephone:
E-mail Address:
Please be aware that any knowing or willful false representations provided in this submission
may constitute a violation of 18 U.S.C. 1001 and are punishable by fine and imprisonment.
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Protection Statement
All PCII materials, or the cases or containers in which they are stored, must be labeled
with the following statement:
This document contains Protected Critical Infrastructure Information.  In accordance with the
provisions of the Critical Infrastructure Information Act, 6 U.S.C. §§ 131 et seq., it is exempt
from release under the Freedom of Information Act (5 U.S.C. § 552) and similar State and local
disclosure laws.  Unauthorized release may result in criminal and administrative penalties. It is
to be safeguarded and disseminated in accordance with the Critical Infrastructure Information
Act, 6 U.S.C. §§ 131 et seq., the implementing Regulation, 6 C.F.R. Part 29 and PCII Program
requirements.
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