TSA Form 2817A SSI Access Threat Assessment Questionaire - LITIGATION

OMB No. 1652-0042; Exp. xx/xx/202x

DEPARTMENT OF HOMELAND SECURITY

Transportation Security Administration

SSI ACCESS THREAT ASSESSMENT QUESTIONNAIRE - LITIGATION

INSTRUCTIONS: Applicant: (1) Unless otherwise noted, complete Sections I through IV. (2) Review the application for accuracy and complete Section V. (3) Use Section VI to provide any explanation required from answers in Sections II through IV. (4) Submit the signed form and all supporting documentation to the program office. (Note: If Known Traveler Number, prior Federal background investigation, or active security clearance is available, do not complete steps 5 and 6 of these instructions unless instructed by TSA.) (5) Complete SSI Access Pre-Enrollment. (6) Schedule a date/time for your in-person SSI Access enrollment at your preferred enrollment center location. Program Office: Review Sections I - VI for completion of required information. (2) Verify all required documentation is included and the request is signed by the Applicant (Section V).(3) Submit package to TVS after confirming appointment completed, if required. Use: For use with members of the public (i.e., non-federal) seeking access to SSI during the litigation process.
Section I. Contact and Personal Information (All Types)
Full Legal Name (last, first, MI)
Aliases and/or Prior Names, if any				Social Security Number (optional)
Name of Employer (optional)			Work Phone Number (optional)				Date of Birth (mm/dd/yyyy)
Email Address (optional)			Place of Birth (City, State, Country)
Country of Citizenship					Gender
Alien Registration Number, if applicable		Non-Immigrant Visa Number, if applicable			Known Traveler Number (KTN)
Passport Country and Number (optional)
Prior Federal Background Investigation or Active Security Clearance for access to classified national security information under E.O. 12958?					If 'Yes', enter date (mm/dd/yyyy)
Reason for Requesting Access to SSI
Section II. Additional Questions (All Applicants)
A	Have you ever been held in contempt for violating a confidentiality or protective order in a judicial or administrative proceeding? If ‘Yes’, please describe each such incident, even if the citation later was withdrawn, suspended or modified in Section V below.					Please select response
B	Have you ever been sanctioned as a result of conduct related to a judicial or administrative proceeding? If ‘Yes’, please describe each such incident, even if the sanction later was withdrawn, suspended or modified in Section V below.					Please select response
C	Do you agree to abide by the TSA instructions concerning the handling of SSI in connection with this proceeding in the absence of any contrary ruling by the Court?					Please select response
Section III. Attorney Applicants Only
A	Are you, and have you always been, in good standing with every bar to which you are, or have been, a member? If ‘No’, please provide a detailed explanation in Section V below.					Please select response
B	Have you ever been denied admission to any bar? If ‘Yes’, please provide a detailed explanation in Section V below.					Please select response
C	Have you ever been disciplined, admonished, suspended, disbarred or otherwise sanctioned by or from any bar of which you are, or have been, a member? If ‘Yes’, please describe each such incident, even if the sanction later was withdrawn, suspended or modified in Section V below.					Please select response

Section III. Attorney Applicants Only
D	Has any person or entity, while represented by you, ever been held in contempt for violating a confidentiality or protective order in a judicial or administrative proceeding? If ‘Yes’, please describe each such incident, even if the citation later was withdrawn, suspended or modified in Section V below.		Please select response
E	Has any person or entity, while represented by you, ever been sanctioned as a result of conduct related to a judicial or administrative proceeding? If ‘Yes’, please describe each such incident, even if the sanction later was withdrawn, suspended or modified in Section V below.		Please select response
Section IV. Court Reporter Applicants Only
A	Are you currently listed on the registry of the National Court Reporters Association, or have you passed an equivalent qualifying examination? If ‘Yes’, please specify in Section V below.		Please select response
B	Have you ever been denied any type of security-related clearance with the Federal government? If ‘Yes’, please provide a detailed explanation in Section V below.		Please select response
C	Have you ever been disciplined or terminated for the mishandling of information? If ‘Yes’, please provide a detailed explanation in Section V below.		Please select response
Section V. Acknowledgments
A - Pursuant to 28 U.S.C. § 1746, I declare under penalty of perjury that the foregoing is true and correct.
Applicant Signature:		Date
B - Should I seek judicial review of TSA’s final decision on my threat assessment, I authorize TSA to release the foregoing and any other information related to my threat assessment to the court(s) presiding over that review.
Applicant Signature:		Date
Section VI. Explanation (Complete only if answers to Sections II through IV indicate need for further explanation.)

PRIVACY ACT STATEMENT: AUTHORITY: 49 USC § 114; HR 5441 Section 525(d); 49 CFR Part 1520. PRINCIPAL PURPOSE(S): TSA

will use this information to conduct a threat assessment on individuals who seek access to Sensitive Security Information (SSI). ROUTINE USE(S): This information may be shared with law enforcement, intelligence, or other government agencies as necessary to identify and respond to potential or actual threats to transportation and under the Privacy Act routine uses identified in the TSA system of records, DHS/ TSA-002 Transportation Security Threat Assessment System. DISCLOSURE: Furnishing this information is voluntary; however, failure to provide the requested information may delay or prevent TSA from completing your security threat assessment, without which you will not be granted access to SSI.

PAPERWORK REDUCTION ACT STATEMENT: TSA is collecting this information to conduct a threat assessment to determine your eligibility to gain access to Sensitive Security Information (SSI) for use in connection with a federal civil court proceeding. This is a voluntary collection of information, but failure to provide the information may result in an inability to approve your eligibility to gain access to SSI for use in connection with a federal civil court proceeding. TSA estimates that the total average burden per response associated with this collection is approximately 131 minutes. If you have any comments regarding this form, you may write to: ATTN: TSA PRA Officer, TSA-11, 601 S. 12th Street, Arlington, VA, 20598-6011. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a valid OMB control number. The OMB number for this for is 1652-0042, which expires xx/xx/202x.

Previous editions of this form are obsolete

TSA Form 2817A (1/21) rev. [File: 2800.9.2-a]

Page 2 of 2