Fillable Printable Form DS-109
Fillable Printable Form DS-109
Form DS-109
I reaffirm that the provisions of the espionage laws, other federal criminal laws and executive orders applicable to the safeguarding of
lassified information have been made available to me; that I have returned all classified information in my custody; that I will not
communicate or transmit classified information to any unauthorized person or organization; that I will promptly report to the Federal Bureau
of Investigation any attempt by an unauthorized person to solicit classified information, and that I
received a security debriefing.
I,
(Please Type or Print)
make the following statement in connection with my
Title 18, U.S. Code
Section Public Money, Property or Records
Gather in g , Tr a ns m itting or Lo s ing
Defense Information
Gathering or Delivering Defense Information
to Aid Foreign Govt.
Disclosure of Classified Information
Diplomatic Codes and Correspondence
Disclosure of Confidential Information
Concealment, Removal, or Mutilation of
Records
641 -
793 -
794 -
798 -
952 -
1905 -
2071 -
Title 50, U.S. Code
Section Communication of Classified Information
by Government Officer or Employee
Penalties for Violation
783(b) -
783(d) -
Title 42, U.S. Code
Section Violation of Specific Sections
Violation of General Sections
Communication of Restricted Data
Receipt of Restricted Data
Tampering With Restricted Data
Disclosure of Restricted Data
2272 -
2273 -
2274 -
2275 -
2276 -
2277 -
DS-0109
03-2015
Signature of Interviewing Officer
Date (mm-dd-yyyy)
Typed Name of Interviewing Officer
Post/Department
Signature in Presence of Interviewing Officer
U.S. Department of State
SEPARATION STATEMENT
Date Signed (mm-dd-yyyy)
Typed Name of Employee
Other Names Used During this Period of Employment
1.
separation from employment in the U.S. Department of State. As used herein, the term "employment" includes all periods of assignment or
detail, as well as any periods of temporary, part-time or intermittent employment therein, and the term "separation" includes suspension for any
period in excess of 30 days, retirement from active duty, transfer to another agency, resignation, furlough to enter military service, etc.
I have surrendered to responsible officials all classified or administratively controlled documents and material with which I w as charged or
which I had in my possession. I am not retaining in my possession, custody, or control, documents or m aterial containing classified or
administratively controlled information furnished to me during the course of such employment or developed as a consequence thereof,
including any diaries, memorandums of conversation, or other documents of a personal nature that contain classified or administratively
controlled information.
2. I have surrendered to responsible officials all unclassified documents, and papers relating to the official business of the Government
acquired by me while in the employ of the Department.
3. I shall not publish, nor reveal to any person, any classified or administratively controlled information of which I have knowledge, or any
other information transmitted to me in confidence in the course of my official duties, unless authorized by officials of the employing
Department empowered to grant permission for such disclosure.
4. I have been advised by the interviewing officer whose name appears below, and understand the criminal penalties relating to U.S.
Government records and information and the use thereof:
These provisions are consistent with and do not supersede, conflict with, or otherwise alter the employee obligations, rights, or liabilit ies created
by existing statute or Executive order relating to (1) classified information, (2) communications to Congress, (3) the reporting to an Inspector
General of a violation of any law, rule, or regulation, or mismanagement, a gross waste of funds, an abuse of authority, or a substantial and
specific danger to public health or safety, or (4) any other whistleblow er protection. The definitions, requirements, obligations, rights, sanctions,
and liabilities created by controlling Executive orders and statutory provisions are incorporated into t his agreement and are controlling.
5.
have have not
6. I have been advised by the interviewing officer whose signature appears below and fully understand that Section 1001 of Title 18, United
States Code, provides criminal penalties for knowingly and willfully falsifying or concealing material fact in a statement or document
submitted to any department or agency of the United States Government concerning a matter under its jurisdiction.
(previously OF109)
