Form TSA Form 2817A TSA Form 2817A SSI Access Threat Assessment Questionaire - LITIGATION

OMB No. 1652-0042; Exp. 03/31/2025

DEPARTMENT OF HOMELAND SECURITY

Transportation Security Administration
SSI ACCESS THREAT ASSESSMENT QUESTIONNAIRE - LITIGATION
INSTRUCTIONS: Applicant: (1) Unless otherwise noted, complete Sections I through IV. Providing the optional data may facilitate expedited

processing. (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)
Date of Birth (mm/dd/yyyy)

Name of Employer (optional)

Work Phone Number (optional)

Email Address (optional)

Place of Birth (City, State, Country)

Country of Citizenship
Alien Registration Number, if applicable

Gender
Non-Immigrant Visa Number, if applicable

Known Traveler Number (KTN)
(optional)

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
(i.e., case number)
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the citation later was withdrawn, suspended or modified in Section V below.

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.

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

Please select response
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

Previous editions of this form are obsolete
TSA Form 2817A (xx/22) rev. [File: 2800.9.2-a]

Page 1 of 3

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.

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

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.
Date

Applicant Signature:

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.
Date

Applicant Signature:

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,
6595 Springfield Center Drive, Springfield, 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 03/31/2025.
Previous editions of this form are obsolete
TSA Form 2817A (xx/22) rev. [File: 2800.9.2-a]

Page 2 of 2