+--------------+---------------------------------------+---+-------------+
| **DOE F      |                                       |   | OMB Control |
| 5631.29**    |                                       |   | No.         |
|              |                                       |   |             |
| **(10/92)**  |                                       |   | 1910-1800   |
|              |                                       |   |             |
| All Other    |                                       |   | OMB Burden  |
| Editions Are |                                       |   |             |
| Obsolete     |                                       |   | Disclosure  |
|              |                                       |   | Statement   |
|              |                                       |   |             |
|              |                                       |   | below       |
+--------------+---------------------------------------+---+-------------+

  ------------------- ------------ ----------- ---------- -------------------
                      **U.S.                              (Facility or
                      Department                          Installation Where
                      of Energy**                         Terminated)

                                                          
  ------------------- ------------ ----------- ---------- -------------------

**SECURITY TERMINATION STATEMENT**

  ----- ----------------------------- ----------------------------- -----
        NAME AND TITLE (Print all     EMPLOYER YOU ARE LEAVING      
        blocks)                                                     

        **     **                     **     **                     

        FUTURE RESIDENCE              NAME AND ADDRESS OF FUTURE    
                                      EMPLOYER                      

        **     **                     **     **                     

        REASON FOR TERMINATION                                      

        **     **                                                   

        SOCIAL SECURITY NUMBER        DATE OF BIRTH                 

        **     **                     **     **                     

        DATE OF TERMINATION           DOE NUMBER (IF KNOWN)         

        **     **                     **     **                     
  ----- ----------------------------- ----------------------------- -----

I make the following statement in connection with the forthcoming
termination of my access authorization (security clearance) granted by
the U.S. Department of Energy (DOE).

1\. In accordance with DOE security regulations, I have destroyed or
transferred to persons designated by the DOE [all]{.underline}
classified documents and material for which I was charged or which I had
in my possession.

2\. I will return to a DOE official or person acting for the DOE all
security badges, credentials, or other identification or access media
issued to me by the DOE or its contractors.

3\. I will not reveal to any person any Restricted Data, Formerly
Restricted Data, or other classified information of which I have gained
knowledge except as authorized by law, regulations of the DOE, or in
writing by officials of the DOE empowered to grant permission for such
disclosure.

4\. I will immediately report to the Federal Bureau of Investigation
(FBI) any attempt by an unauthorized individual to acquire classified
information from me.

5\. I am aware that the Atomic Energy Act of 1954 and U.S. Code, Title
18 "Crimes and Criminal Procedures," prescribe penalties for
unauthorized disclosure of Restricted Data, Formerly Restricted Data,
and other information relating to the national defense.

6\. I am aware that I may be subject to criminal penalties if I have
made any statement of material facts knowing that such statement is
false or if I willfully conceal any material fact (Title 18, U.S. Code,

Section 1001).

+---------------------------------+---+---------------------------------+
| (Signature of Person Conducting |   | (Signature of Person Whose      |
| Interview)                      |   | Access                          |
|                                 |   |                                 |
|                                 |   | Authorization is Being          |
|                                 |   | Terminated)                     |
+---------------------------------+---+---------------------------------+

  --------------------------------- -- ----------------------------------
  (Title of Position)                  (Date)

  --------------------------------- -- ----------------------------------

**See Reverse for Privacy Act Statement.**

+--------------+---------------------------------------+---+-------------+
| **DOE F      |                                       |   | OMB Control |
| 5631.29**    |                                       |   | No.         |
|              |                                       |   |             |
| **(10/92)**  |                                       |   | 1910-1800   |
|              |                                       |   |             |
| All Other    |                                       |   |             |
| Editions Are |                                       |   |             |
| Obsolete     |                                       |   |             |
+--------------+---------------------------------------+---+-------------+

**[PRIVACY ACT STATEMENT]{.underline}**

Collection of the information requested is authorized by the Atomic
Energy Act of 1954, as amended, and by Executive Orders 10450, 10865,
and 12356.

Disclosure of the information on this form is voluntary; however, your
decision not to complete this form could result in a delay in processing
any future request for reinstatement of your U.S. Department of Energy
(DOE) access authorization (security clearance). Your DOE access
authorization can be terminated regardless of whether this form is
completed. Your name, Social Security Number, and date of birth are used
as identifying factors to establish and maintain records of DOE access
authorization actions in the DOE System of Records, DOE-42, "Personnel
Security Clearance Index," and this form will be maintained in your DOE
Personnel Security File (DOE System of Records, DOE-43, "Personnel
Security Clearance Files"). Access to these records is permitted as
stipulated in DOE 5631.2, "Personnel Security Program," and as listed in
Routine Uses in Appendix B to the DOE System of Records.

**[OMB BURDEN DISCLOSURE STATEMENT]{.underline}**

Public reporting burden for this collection of information is estimated
to average 5 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 this burden estimate or any other
aspect of this collection of information, including suggestions for
reducing this burden, to Office of Information Resources Management,
AD-241.2 - GTN, Paperwork Reduction Project (1910-1800), U.S. Department
of Energy, 1000 Independence Avenue, S.W., Washington D.C. 20585; and to
the Office of Management and Budget, Paperwork Reduction Project
(1910-1800), Washington, D.C. 20503.