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INTERCONTINENTAL BALLISTIC MISSILE HARDENED INTERSITE CABLE
RIGHT-OF-WAY LANDOWNER/TENANT QUESTIONNAIRE

OMB NO. 0701-0141
Expires:

The public reporting burden for this collection of information, OMB Control Number 0701-0141, is estimated to average 15 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. Please DO NOT RETURN your form to the email address above. Please complete questionnaire on reverse of this form and return in
pre-addressed, postage paid envelope provided. If pre-addressed envelope is not used, please send your completed form to the local missile complex
maintenance unit's office.

PRIVACY ACT STATEMENT
AUTHORITY: 10 U.S.C. 9013, Secretary of the Air Force; powers and duties; delegation by.
PURPOSE: Used to track, monitor, and coordinate activities (i.e., highway crossing, utility crossing, construction, earth moving, etc.)
affecting the Hardened Intersite Cable System (HICS) and/or its right-of-ways (ROWS) and could impair HICS hardness integrity.
ROUTINE USES: No disclosures will be made outside of DoD.
DISCLOSURE: Furnishing information is voluntary. Failure to provide the information would greatly impair the ability of the U.S. Air Force
to schedule and coordinate missile cable maintenance efforts with affected landowners/tenants.
SYSTEM OF RECORDS NOTICE: F021 AFGSC A Cable Affairs Personnel/Agency Records
1. LANDOWNER/TENANT INFORMATION:

AF FORM 3951, XXXXXXX (IMT-V1)

PREVIOUS EDITIONS ARE OBSOLETE.

2. IS LANDOWNER/TENANT INFORMATION SHOWN ON FRONT OF THIS FORM CORRECT/COMPLETE?

YES

NO

IF NO, PLEASE CORRECT OR INCLUDE THE INFORMATION. IF YOU ARE THE LANDOWNER AND THE TENANT INFORMATION ON THIS FORM IS INCORRECT,
PLEASE PROVIDE CURRENT TENANT INFORMATION; INCLUDE CURRENT TENANT'S NAME, ADDRESS, AND TELEPHONE NUMBER.

3. DO YOU HAVE OR KNOW OF ANY OF THE FOLLOWING CONDITIONS CONCERNING THE MISSILE CABLE ROUTE,CONDUIT, INNERDUCT, OR FIBER
OPTIC (HEREINAFTER REFERRED TO AS "CABLE ROUTE") ON YOUR PROPERTY? IF YES, PLEASE PROVIDE THE LOCATION IN THE SPACE PROVIDED.
a. DEVELOPING EROSION ALONG THE MISSILE CABLE ROUTE AND/OR EXPOSED MISSILE CABLE.

YES

NO

b. MISSILE CABLE FENCE/ACCESS GATES DAMAGED AND/OR REQUIRING REPAIR.

YES

NO

c. MISSILE CABLE ROUTE MARKER POSTS DAMAGED, LEANING, OR DOWN.

YES

NO

YES

NO

4. DO YOU HAVE ANY PROJECTS OR ACTIONS (such as construction or excavations) PLANNED FOR AREAS ON OR NEAR THE
MISSILE CABLE ROUTE?
IF YES, PLEASE PROVIDE SOME GENERAL INFORMATION AND LOCATION OF YOUR PLANNED PROJECT/ACTION.

THANK YOU FOR YOUR TIME AND EFFORTS IN COMPLETING THIS FORM.

AF FORM 3951, XXXXXXX (REVERSE) (IMT-V1)