Form Exchange Form 3900 Exchange Form 3900 Statement

ARMY AND AIR FORCE EXCHANGE SERVICE

OMB NO. 0702-0138
OMB approval expires
XXX, XX, XXXX

STATEMENT
EXCHANGE FORM 3900-017
AGENCY DISCLOSURE NOTICE

PRIVACY ACT STATEMENT

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The public reporting burden for this collection of information, 0702-0138, is estimated to average 60 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 the burden estimate or burden reduction
suggestions to the Department of Defense, Washington Headquarters Services, at [email protected]. Respondents should be aware that notwithstanding any other provision of law, no person shall be subject
to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control
number.

AUTHORITY: 10 U.S.C. 7013, Secretary of the Army; 10 U.S.C. 9013, Secretary of the Air Force; Army Regulation 215-

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8/AFI 34-211(I), Army and Air Force Exchange Service Operations; Federal Claims Collection Act of 1966 (Pub.L. 89-508,
as amended); Debt Collection Act of 1982 (Pub.L. 97-365, as amended), as codified in 31 U.S.C. §3711, Collection and
Compromise; 31 CFR 285.11, Administrative Wage Garnishment; E.O. 12196, DoD Instruction 1330.21, Armed Services
Exchange Regulations; DoD 7000.14-R, Department of Defense Financial Management Regulation Volume 13,
Nonappropriated Funds Policy and Volume 16, Department of Defense Debt Management; Army Regulation 27-20, Chapter
4, Legal Service Claims; Air Force Instruction 51-501 implementing Air Force Policy Memorandum AFPD51-5, Section A,
Administrative Claims; and E.O. 9397 (SSN), as amended.
PRINCIPAL PURPOSE(S): To record incidents involving Government property such as alleged unrecorded concession theft,
larceny, and alleged employee theft; employee and concessionaire misconduct; fraudulent activities; and claims of workplace
violence which could result in further administrative actions or civil/criminal prosecution. Information is used for the
investigative purposes of recouping damages, correcting deficiencies, initiating appropriate disciplinary action; and for
managerial and statistical reports.
ROUTINE USE(S): Your records may be disclosed outside of DoD pursuant to Title 5 U.S.C. §552a(b)(3) regarding DoD “Blanket
Routine Uses” published at http://dpcld.defense.gov/Privacy/SORNsIndex/BlanketRoutineUses.aspx. This system of records contains
individually identifiable health information.

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DISCLOSURE: Voluntary, however, refusal to provide information, concealment, or misrepresentation of material facts reported on
this statement may impede the investigation.
A copy of the Privacy Impact Assessment (PIA) for the collection of information may be located at https://www.aafescom/aboutexchange/public-affairs/FOIA/assessments.htm.
SYSTEM OF RECORD NOTICE: Exchange 0409.01 “Exchange Accident/Incident Reports”:
http://dpcld.defense.gov/Privacy/SORNsIndex/?Category=11160&Page=8

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INSTRUCTIONS

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4.

Please review the attached detailed instructions before completing the attached statement.
Follow any verbal instructions provided to you by your interviewer or local authority.
Complete the statement in its entirety.
When directed and only after verifying the accuracy of the information, initial each page and sign as Directed by
your interviewer or local authority.

5. You may ask for a copy of your statement from your interviewer or local authority.
6. Direct all questions to your interviewer or local authority.
Acknowledge of receipt:

EXCHANGE FORM 3900-017 (DRAFT)

Signature of Interviewee

Detailed Instructions
Completions of Exchange Form 3900-017
Please be certain to read the Agency Disclosure Notice and Privacy Act Statement before
completing.
A witness should report and furnish information on this statement freely without hope,
benefit or reward, whether favorable or unfavorable, regarding matters of official interest
as may be required by competent authority.
Your interviewer will complete most of the top of the statement other than your name
and personal information.
Please complete the following sections of the form.

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1. Type or print all information in ink. Please make sure the information is complete and
accurate.
2. Name section: Include your first name, middle initial and last name.

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3. DOH (Date of Hire); If an AAFES Associate, please put your hire date, otherwise leave
blank.
4. If you are a military service member or an AAFES associate, please also
complete your grade and position in the area requested.
5. After given directions from your interviewer or local authority, please
complete your statement to the best of your knowledge. Include actions involved
in the incident or inquiry being questioned about.
a. Your statement should be honest, given without coercion, influence or
inducement.
b. Please be clear providing enough detail to substantiate your answers to
questions or display your view of the incident/inquiry.

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c. If at all possible, please specify dates and times of occurrences.

Upon completion of your statement submit it to your interviewer or local authority who will read and
review it. When the statement is returned to you, please review and if you have nothing to add or
change, initial each page and sign the last page. Be sure to read the text above the signature page
before signing. Present the statement again to your interviewer who will then sign the form.

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You are entitled to a copy of the statement upon request.

EXCHANGE FORM 3900-017 (DRAFT)

INTERVIEW CONDUCTED AT:

ARMY AND AIR FORCE EXCHANGE SERVICE

STATEMENT

FIRST NAME, MI, LAST NAME:

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INSTALLATION ASSIGNED:

BRANCH NAME/NUMBER

INTERVIEWED BY:

NATURE OF INQUIRY

GRADE

POSITION

DICP

INTERVIEW BEGAN

HOUR

DAY

MONTH

YEAR

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STATEMENT

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CONTINUATION SHEET FOR EXCHANGE FORM 3900-017

I have made this statement freely without hope of benefit or reward, without threat of punishment, and without coercion, influence or
inducement. I further state that I have read the entire statement, initialed all pages and corrections, and that it is correct and true as
written. Furthermore, I understand that refusal to provide information/concealment or misrepresentation of material facts in a report or
statement will constitute grounds for separation for cause or other disciplinary action.

WITNESSES:

INTERVIEW CONCLUDED: HR ______ DAY ______ MONTH ______ YR ______

Signature or Interviewee

Signature

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