Fillable Printable Security Termination Statement
Fillable Printable Security Termination Statement
Security Termination Statement
INITIALS
SIGNATURE
SECURITY TERMINATION STATEMENT
For use of this form, see AR 380-5; proponent agency is OACSI.
For use of this form, see AR 380-5; the proponent agency is OACSI.
A. APPLICABLE TO ALL PERSONNEL WHO HAVE HAD ACCESS TO DEFENSE INFORMATION:
B. ADDITIONALLY APPLICABLE TO PERSONNEL WHO HAVE HAD ACCESS TO
RESTRICTED DATA:
C. OTHER
(Specify)
(1) ESPIONAGE LAWS: TITLE 18, U.S. CODE, SECTIONS 793, 794, AND 798
("temporary extension of Section 794")
(2) INTERNAL SECURITY LAWS: TITLE 50, U.S. CODE, SECTION 783.
(3) DOD REGULATION 5200.1-R, AR 380-5.
(1) ATOMIC ENERGY ACT OF 1954: TITLE 42, U.S. CODE, SECTIONS 2014, 2162, 2274, 2275, 2276, AND 2277.
(2) AR 380-150.
1. I acknowledge that I have read the applicable material for the level of classified information to which I have had access, and I understand that the revelation of classified
information to an unauthorized person or agency is prohibited and punishable by law. My initials below attest to the level of access which I have had and to the applicable
material, as identified in References, which I have read.
2. I do not have classified material or documents in my possession.
3. I will not divulge classified information orally, in writing, or by any other means, to an unauthorized person or agency.
4. I will immediately report to the Federal Bureau of Investigation, my superior/commander, or other military authority, as appropriate, any attempt by an
unauthorized person or agency to obtain classified information.
5. I received an oral debriefing, immediately prior to the execution (i.e., signature) of this Security Termination Statement.
PART III - SECURITY TERMINATION AND DEBRIEFING STATEMENT
PART II - REFERENCES
FROM
(
Originating Headquarters)
DATE
GRADE
(Mil or Civ)
NAME
(Last, first, middle initial)
SOCIAL SECURITY NUMBER
DISTRIBUTION:
EDITION OF 1 JAN 71 MAY BE USED.
PART I - BASIC INFORMATION
a. TOP SECRET - SECRET - CONFIDENTIAL defense information
(Reference a).
b. RESTRICTED DATA
(Reference b)
.
c. Other
(Specify)
FIELD 201 FILE
(Military)
LOCAL SECURITY FILE
EXTENT OF ACCESS
DA FORM 2962, SEP 1977
APD LC v2.01ES
OUTLINE OF GENERAL CONTENT ORAL SECURITY DEBRIEFING
(Part of Security Termination Statement)
1. PURPOSE OF DEBRIEFING. a. To establish that the individual does in fact understand the implications, to
national security, and to him/her self, of the statutes and regulations which he/she has read.
b. To emphasize to the individual that he/she was afforded access to classified information solely because
of his/her "need-to-know" in the performance of official duties; that this information was entrusted, as well as
officially charged to him/her; and that his/her impending separation, in no way lessens his/her responsibilities -
and liabilities - for ensuring that the classified knowledge acquired is not divulged in any manner to an
unauthorized person or agency.
2. SERIOUS NATURE OF THE SUBJECT MATTER WHICH REQUIRES PROTECTION. Emphasize to the
individual that classified information is defined and described in the pertinent statutes and regulations which he/she
has read. As an illustration, cite the fact that
SECRET
defense information is "information or material the un-
authorized disclosure of which
COULD RESULT IN SERIOUS DAMAGE TO THE NATION
". Where the individual has
had access to
TOP SECRET, RESTRICTED DATA,
compartmented information, cite the specific definition(s) and
description(s) and emphasize that such material is even more serious in nature.
3. NEED FOR CAUTION AND DISCRETION. a. Emphasize to the individual that the responsibility is
HIS/HER's
to specifically establish that a person or agency requesting any classified information is officially
authorized
(NEED-TO-KNOW)
that information; that if he/she is leaving the service
(includes civilian
employees)
, absolutely no other person or agency is authorized the classified information.
4. SUMMARY. Specifically ask the individual if he understands what he/she has read and what he/she is about to
sign. Based on his/her response
(and questions he/she may raise)
re-emphasize the content of the Security
Termination Statement.
b. Emphasize to the individual that the mere fact that he/she reads a news article which appears to contain
classified information in no way authorizes him/her to confirm or deny the item. Explain that good "guesses"
frequently are reflected by the news media, but bad "guesses" and incorrect information also are included.
c. Caution the individual that history records a number of cases involving unauthorized disclosures in clubs
and at social gatherings which have been reported and which resulted in punitive action.
APD LC v1.00
