1 Bc 1759

FORM BC-1759(ef)
(6-27-2012)

U.S. DEPARTMENT OF COMMERCE
Economics and Statistics Administration

U.S. CENSUS BUREAU

SPECIAL SWORN STATUS
PART A – IDENTIFICATION
Month

1. Print full Legal Name – Last, First, Middle (If no middle name enter "NMN", otherwise spell out)

Day

Year

2. Date of birth
3. Place of birth – City
and State or Country
Citizenship
4. Local home address

Home telephone number

5. Name and address of present employer

6. Prior investigation
contact:
Telephone number

PART B – WAIVER OF COMPENSATION
I, the undersigned, offer my services to the U.S. Census Bureau with Special Sworn Status on a voluntary/contractor basis without compensation. On
behalf of myself and my heirs and assigns, I release and discharge the Government of the United States from any claims, suits, or demands that I or my
heirs or assigns may, can, or shall have in connection with compensation for my volunteer/contractor services for the Government of the United States.
Signature
Date
Witness signature

Date

PART C – AFFIDAVIT OF NON-DISCLOSURE
I,
, do solemnly swear (or affirm) I will not
disclose any information contained in the schedules, lists, or statements obtained for or prepared by the U.S. Census Bureau to any
person or persons either during or after appointment. (Under title 13, U.S.C. section 214 and title 18, U.S.C. 3551, et. seq., the
penalty for unlawful disclosure is a fine of not more than $250,000 or imprisonment for not more than 5 years, or both.)

(Signature of appointee)
Subscribed and sworn (or affirmed) before me this

day of

, 20

,

at

,

.

(City)

(State)

[SEAL]
Signature
My commission expires
Title (Officer/Notary Public)
NOTE – The oath of nondisclosure must be administered by a person specified in 5 U.S.C. §2903. The word "swear"
wherever it appears above should be stricken out when the appointee elects to affirm rather than swear to the
affidavit; only these words may be stricken and only when the appointee elects to affirm the affidavit.

PART D – DIVISION/OFFICE AUTHORIZATION
a. Div. & Org. code b. Census facility
1. Work
location
d. Room
4. Approving
Census
Official

c. Non-Census 2. Date Start

e. Office telephone number

3. Special access:
(Attach documentation)

Proposed end

a. COTR/Division Chief – Type

b. Approver’s telephone number

c. Signature

d. Date of request

PART E – TO BE COMPLETED BY SECURITY
1. Approved by Security

2. Badge issued
for – Specify
time limit.

3. Fingerprints required
Yes

No

4. Renewal
Yes

5. Badge issued

PRIVACY ACT STATEMENT
Authority for the collection of your personal information on form BC-1759, Special Sworn Status, is
provided under 13 U.S.C. § 23c.
The purpose for collecting this information is to document the granting of the Special Sworn Status
designation to temporary Census Bureau employees (contractors) and other individuals who require
workrelated access to information protected under Title 13 U.S.C. The information collected includes
name, date of birth, place of birth, local home address, and present employer’s name and address. The
form also collects a signed affidavit of non-disclosure that obligates individuals to accept responsibility
for keeping all Title 13 data confidential.
Disclosure of the information provided to us is permitted under the Privacy Act of 1974 (5 U.S.C. Section
552a) and may be shared with other Census Bureau staff for the work-related purposes identified in this
statement.
Furnishing this information is voluntary. Failure to provide this information, however, will not allow you to
have access to information protected under Title 13 U.S.C. and may prevent employment with the U.S.
Census Bureau.
EXPLANATION OF SPECIAL SWORN STATUS
(BC-1759)
Part A:

Completed by the special sworn/contractor. Contractors who are not U.S. citizens
should bring INS documentation with them.

Part B:

Signed by the special sworn/contractor in the presence of a witness. The witness
should be either a Census Bureau employee authorized by the Security Office or a
notary public.
Note: Signature for Part B of the BC-1759 is a Human Resources Division
requirement. Individuals working as contractors or volunteers are not paid
employees of the U.S. Census Bureau; therefore, they do not receive the benefits
of the Bureau’s payroll system. Volunteers receive no compensation. Contractors
are paid through a contractual agreement with the Bureau’s procurement office or
sponsoring division.

Part C:

Signed by the special sworn/contractor in the presence of either a Census Bureau
employee authorized to administer the oath of non-disclosure or a notary public.
Note: Special sworn/contractors who refuse to sign Part C will not be allowed to
have access to Census Bureau facilities or information.

Part D:

Signed by the authorized Contracting Officer’s Technical Representative (COTR) or
the sponsoring Division Chief.
Note: Part D MUST be completed before the Security Office will initiate any
action on the security processing or issuance of a building pass. Special Access
includes 24-hour access and proxy card access, which require additional
documentation. For further information, contact the Security Office. The authorized
signature in Part D indicates that the COTR or Division Chief is responsible for the
actions of the special sworn/ contractor.

Renewals: Contractors complete Part A of BC-1759, and COTR or Division Chief completes
Part D. Contractor brings completed form to Security Office for approval.
FORM BC-1759(ef) (6-27-2012)