DOE F 5631.29 Security Termination Statement

DOE F 5631.29
(10/2021)
All Other Editions are Obsolete

U.S. Department of Energy
SECURITY TERMINATION STATEMENT

Full Name (Print- Last, First Middle):

Employer Associated with Security Termination:

OMB Control No.
1910-1800
Expires 10/31/2021

Social Security Number:

Facility/Installation Where Security Terminated:

Contract Number(s) (if contractor)
Remarks/Reason for Security Termination (please use plain language reasoning)

Date of Security Termination:

DOE Clearance Number (If known):

Present/Future Residence:

Name and Address of Future Employer (if know):

PURPOSE
This form is to be completed when an individual’s DOE access authorization/security clearance is terminated or administratively withdrawn, in
accordance with DOE O 472.2, “Personnel Security,” and DOE O 470.4B, “Safeguards and Security,” or successor directives. Termination will be recorded
in personnel security files/databases. Document any variations in Remarks/Reason for Security Termination section, above.

PLEASE READ THE FOLLOWING IN ITS ENTIRETY (Continued on second page)
I hereby make the following statement in connection with the forthcoming termination of my access authorization/security clearance granted by the
U.S. Department of Energy (DOE):
1. I have been advised that the unauthorized disclosure, unauthorized retention, or negligent handling of classified information by me could
cause damage or irreparable injury to the United States or could be used to advantage by a foreign nation. I hereby agree that I will never
divulge classified information to anyone unless: (a) I have officially verified that the recipient has been properly authorized by the United States
Government to receive it; or (b) I have been given prior written notice of authorization from the United States Government Department or
Agency (hereinafter Department or Agency) responsible for the classification of information or last granting me a security clearance that such
disclosure is permitted. I understand that if I am uncertain about the classification status of information, I am required to confirm from an
authorized official that the information is unclassified before I may disclose it, except to a person as provided in (a) or (b), above. I further
understand that I am obligated to comply with laws and regulations that prohibit the unauthorized disclosure of classified information.
2. I have been advised that any unauthorized disclosure of classified information by me may constitute a violation, or violations, of United
States criminal laws, including the provisions of sections 641, 793, 794, 798, 952 and 1924, title 18, United States Code; the provisions of
section 783(b), title 50, United States Code; and the provisions of the Intelligence Identities Protection Act of 1982. I recognize that nothing in
this Agreement constitutes a waiver by the United States of the right to prosecute me for any statutory violation.
3. I hereby assign to the United States Government all royalties, remunerations, and emoluments that have resulted, will result or may result
from any disclosure, publication, or revelation of classified information not consistent with the terms of this Agreement.
4. I understand that all classified information to which I had access or may have obtained access by signing this Agreement is now and will
remain the property of, or under the control of the United States Government unless and until otherwise determined by an authorized official or
final ruling of a court of law. I have returned all classified materials which came into my possession or for which I was responsible because of
such access. I further understand that if I did not return such materials, I understand that this may be a violation of sections 793 and/or 1924,
title 18, United States Code, a United States criminal law.
OFFICIAL USE ONLY
May be exempt from public release under the Freedom
of Information Act (5 U.S.C. 552) Exemption (b)(6) Personal
Privacy. Department of Energy review required before public release.
Name/Org:
Date:

Guidance

OFFICIAL USE ONLY

OMB Control No.
1910-1800
Expires 10/31/2021

DOE F 5631.29
(10/2021)
All Other Editions are Obsolete

5.
I am aware that the Section 224, Atomic Energy Act of 1954, as amended; and/or Sections 794, 798, and 1924 of U.S. Code, Title 18 ``Crimes and
Criminal Procedures,'' prescribe penalties for unauthorized disclosure, via any means, of Restricted Data (RD), Formerly Restricted Data (FRD),
Transclassified Foreign Nuclear Information (TFNI) , and other classified information relating to the national defense. I am further aware that I may be
subject to criminal penalties if I have made any statement of material facts knowing that such statement is false or if I willfully conceal any material fact.
6. In accordance with DOE security regulations, I have destroyed or transferred to persons designated by the DOE all classified matter and material, and
applicable controlled documents for which I was charged or which I had in my possession.
7. I have returned to a DOE official or person acting for the DOE all security badges, credentials as required, or other identification or access media issued
to me by the DOE or its contractors.
8. I will immediately report to the Federal Bureau of Investigation (FBI) any attempt by an unauthorized individual to acquire from me classified or
applicable controlled information.
9. Unless and until I am released in writing by an authorized representative of the United States Government, I understand that all conditions
and obligations imposed upon me by this Agreement apply during the time I am granted access to classified information, and at all times
thereafter.
10. I have read this Agreement carefully and my questions, if any, have been answered.

OMB BURDEN DISCLOSURE STATEMENT
Public reporting burden for this collection of information is estimated to average 5 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. The collection of this information is mandatory to protect national security and other critical assets entrusted
to the Department. Send comments regarding this burden estimate or any other aspect of this collection of information, including
suggestions for reducing this burden, to Office of Environment, Health, Safety and Security, U.S. Department of Energy, 1000
Independence Avenue, S.W., Washington, D.C. 20585; and to the Office of Management and Budget (OMB), Paperwork Reduction
Project (1910-1800), Washington, DC 20503.
PRIVACY ACT STATEMENT
Collection of the information requested is authorized by the Atomic Energy Act of 1954, as amended, and by Executive Orders 13764,
10865, and 13526. The collection of this information is mandatory to protect national security and other critical assets entrusted to the
Department. Your DOE access authorization/security clearance can be terminated regardless of whether this form is completed. Your
name and Social Security Number are used as identifying factors to establish and maintain records of DOE access authorization actions
in the DOE System of Records, DOE-43, "Personnel Security Files," and this form will be completed and maintained in your DOE
Personnel Security File. Access to this record, within DOE and by and other individuals, is permitted in accordance with the Privacy
Act of 1974, as amended, 10 CFR 1008, and for routine uses in System of Records, DOE -43, "Personnel Security Files."

(Signature of Debriefing Official)

(Title of Debriefing Official)

Debrief Date
(Printed/Typed Name of Debriefing Official)
Only check if Subject is not available for debrief
(Signature of Person Whose Access Authorization/
Security Clearance is Being Terminated)

OFFICIAL USE ONLY