+------------+-----+---------------+------+---------------------------+
| !          |     |               |      |                           |
| [](media/i |     |               |      |                           |
| mage1.wmf) |     |               |      |                           |
+------------+-----+---------------+------+---------------------------+
| **JUS      |     |               |      |                           |
| TIFICATION |     |               |      |                           |
| FOR        |     |               |      |                           |
| REQUESTED  |     |               |      |                           |
| SECURITY   |     |               |      |                           |
| C          |     |               |      |                           |
| LEARANCE** |     |               |      |                           |
+------------+-----+---------------+------+---------------------------+
| *[Instru   |     |               |      |                           |
| ctions]{.u |     |               |      |                           |
| nderline}: |     |               |      |                           |
| This form  |     |               |      |                           |
| is to be   |     |               |      |                           |
| prepared   |     |               |      |                           |
| and        |     |               |      |                           |
| submitted  |     |               |      |                           |
| for each   |     |               |      |                           |
| security   |     |               |      |                           |
| clearance  |     |               |      |                           |
| requested. |     |               |      |                           |
| The        |     |               |      |                           |
| jus        |     |               |      |                           |
| tification |     |               |      |                           |
| statement  |     |               |      |                           |
| must       |     |               |      |                           |
| sp         |     |               |      |                           |
| ecifically |     |               |      |                           |
| explain    |     |               |      |                           |
| the need   |     |               |      |                           |
| for access |     |               |      |                           |
| to         |     |               |      |                           |
| classified |     |               |      |                           |
| national   |     |               |      |                           |
| security   |     |               |      |                           |
| i          |     |               |      |                           |
| nformation |     |               |      |                           |
| and the    |     |               |      |                           |
| highest    |     |               |      |                           |
| level of   |     |               |      |                           |
| access     |     |               |      |                           |
| required.  |     |               |      |                           |
| See the    |     |               |      |                           |
| following  |     |               |      |                           |
| in         |     |               |      |                           |
| structions |     |               |      |                           |
| for        |     |               |      |                           |
| additional |     |               |      |                           |
| help.*     |     |               |      |                           |
+------------+-----+---------------+------+---------------------------+
| **EMPLOYEE |     |               | **   |                           |
| NAME:**    |     |               | OFFI |                           |
|            |     |               | CIAL |                           |
|            |     |               | POSI |                           |
|            |     |               | TION |                           |
|            |     |               | TITL |                           |
|            |     |               | E:** |                           |
|            |     |               |      |                           |
|            |     |               |      |                           |
|            |     |               |      |                           |
+------------+-----+---------------+------+---------------------------+
| *          |     | **SSN:**      | **S  |                           |
| *AGENCY:** |     |               | TATU |                           |
|            |     |               | S:** |                           |
| **     **  |     |               |      |                           |
|            |     |               | Empl |                           |
|            |     |               | oyee |                           |
|            |     |               | Co   |                           |
|            |     |               | ntra |                           |
|            |     |               | ctor |                           |
|            |     |               | O    |                           |
|            |     |               | ther |                           |
+------------+-----+---------------+------+---------------------------+
| **POSITION |     |               | **C  |                           |
| S          |     |               | LEAR |                           |
| ENSITIVITY |     |               | ANCE |                           |
| LEVEL:**   |     |               | L    |                           |
|            |     |               | EVEL |                           |
| Special    |     |               | REQU |                           |
| Sensitive  |     |               | ESTE |                           |
| (4)        |     |               | D:** |                           |
|            |     |               |      |                           |
| Critical   |     |               | TS   |                           |
| Sensitive  |     |               | /SCI |                           |
| (3)        |     |               | (4)  |                           |
|            |     |               |      |                           |
| No         |     |               | Top  |                           |
| n-Critical |     |               | Se   |                           |
| Sensitive  |     |               | cret |                           |
| (2)        |     |               | (3)  |                           |
|            |     |               |      |                           |
|            |     |               | Se   |                           |
|            |     |               | cret |                           |
|            |     |               | (2)  |                           |
|            |     |               |      |                           |
|            |     |               | Conf |                           |
|            |     |               | iden |                           |
|            |     |               | tial |                           |
|            |     |               | (1)  |                           |
+------------+-----+---------------+------+---------------------------+
| *          |     |               |      |                           |
| *CLEARANCE |     |               |      |                           |
| JUSTIF     |     |               |      |                           |
| ICATION:** |     |               |      |                           |
|            |     |               |      |                           |
| *(Please   |     |               |      |                           |
| read the   |     |               |      |                           |
| attached   |     |               |      |                           |
| in         |     |               |      |                           |
| structions |     |               |      |                           |
| for        |     |               |      |                           |
| acceptable |     |               |      |                           |
| just       |     |               |      |                           |
| ifications |     |               |      |                           |
| and        |     |               |      |                           |
| further    |     |               |      |                           |
| in         |     |               |      |                           |
| struction. |     |               |      |                           |
| If an      |     |               |      |                           |
| Interim    |     |               |      |                           |
| clearance  |     |               |      |                           |
| is needed  |     |               |      |                           |
| due to     |     |               |      |                           |
| e          |     |               |      |                           |
| xceptional |     |               |      |                           |
| circ       |     |               |      |                           |
| umstances, |     |               |      |                           |
| please     |     |               |      |                           |
| sp         |     |               |      |                           |
| ecifically |     |               |      |                           |
| state      |     |               |      |                           |
| reasons    |     |               |      |                           |
| why in     |     |               |      |                           |
| your       |     |               |      |                           |
| just       |     |               |      |                           |
| ification. |     |               |      |                           |
| See page   |     |               |      |                           |
| 2)*        |     |               |      |                           |
|            |     |               |      |                           |
| *     *    |     |               |      |                           |
+------------+-----+---------------+------+---------------------------+
| **DATE OF  | **R |               |      | **REQUESTING OFFICIAL:**  |
| REQUEST:** | EQU |               |      | *(signature)*             |
|            | EST |               |      |                           |
| **     **  | ING |               |      |                           |
|            | OF  |               |      |                           |
|            | FIC |               |      |                           |
|            | IAL |               |      |                           |
|            | :** |               |      |                           |
|            | *(  |               |      |                           |
|            | pri |               |      |                           |
|            | nte |               |      |                           |
|            | d)* |               |      |                           |
|            |     |               |      |                           |
|            | *   |               |      |                           |
|            |     |               |      |                           |
|            |   * |               |      |                           |
+------------+-----+---------------+------+---------------------------+
| *I have    |     |               |      |                           |
| read the   |     |               |      |                           |
| jus        |     |               |      |                           |
| tification |     |               |      |                           |
| statement  |     |               |      |                           |
| above      |     |               |      |                           |
| relating   |     |               |      |                           |
| to the     |     |               |      |                           |
| need for a |     |               |      |                           |
| security   |     |               |      |                           |
| clearance. |     |               |      |                           |
| If         |     |               |      |                           |
| granted, I |     |               |      |                           |
| will be    |     |               |      |                           |
| required   |     |               |      |                           |
| to sign a  |     |               |      |                           |
| Non        |     |               |      |                           |
| disclosure |     |               |      |                           |
| Agreement  |     |               |      |                           |
| at the     |     |               |      |                           |
| time of my |     |               |      |                           |
| initial    |     |               |      |                           |
| security   |     |               |      |                           |
| briefing.  |     |               |      |                           |
| I am also  |     |               |      |                           |
| aware that |     |               |      |                           |
| if this    |     |               |      |                           |
| clearance  |     |               |      |                           |
| is granted |     |               |      |                           |
| at the Top |     |               |      |                           |
| Secret     |     |               |      |                           |
| level that |     |               |      |                           |
| I will be  |     |               |      |                           |
| subject to |     |               |      |                           |
| random     |     |               |      |                           |
| drug       |     |               |      |                           |
| testing.*  |     |               |      |                           |
|            |     |               |      |                           |
| **         |     |               |      |                           |
| EMPLOYEE'S |     |               |      |                           |
| SI         |     |               |      |                           |
| GNATURE:** |     |               |      |                           |
|            |     |               |      |                           |
| **DATE:**  |     |               |      |                           |
+------------+-----+---------------+------+---------------------------+

**[Justification for Requested Security Clearance form
instructions]{.underline}**

All requests for security clearances, with the exception of
reinvestigations involving the same position titles and designations,
require specific justification explaining the need for access to
classified national security information as it relates to an
individual's duties. Eligibility for access to classified information
shall only be granted based on a demonstrated, foreseeable need for
access. All requests for interim security clearances must state the
nature of the official functions that require access to classified
information or facilities, which must be performed before completion of
the investigative and adjudicative process.

Requests such as "...requires a security clearance in the performance of
his duties..." without additional detail **will not be accepted**. All
unacceptable requests will be returned for clarification. An appropriate
and specific justification for access to classified information should
clearly state:

1.  *The level of clearance required*

2.  *The [specific]{.underline} duties that require access to classified
    information*

3.  *Include where the access will occur and the frequency of access*

**Employees requiring access to TS/SCI [must]{.underline} provide
detailed information to the following questions**:

1.  What SCI compartments are needed for this position? Compartments
    must be listed.

2.  On what will you be working that requires SCI access?

3.  With whom will you be interacting?

4.  What type of documents will you need to review?

5.  What systems will you access?

6.  What other relevant information can you provide regarding the need
    for SCI access as it relates to your duties and your agencies
    mission?

In addition, **an SES level supervisor must sign all SCI requests
(exceptions may apply).** If you have any questions, or if you need
further assistance, please contact Susan Gulbranson, Chief, Personnel &
Document Security Branch, at 202/205-9345.

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  **NOTICE**: The Privacy Act, 5 U.S.C. 552a, requires that federal
  agencies inform individuals at the time information is solicited from
  them, whether the disclosure is mandatory or voluntary, by what
  authority such information is solicited, and what uses will be made of
  the information. You are hereby advised that authority for soliciting
  your Social Security Number (SSN) is Executive Order 9397. Your SSN is
  needed to keep records accurate because other people many have the same
  name and birth date. Your SSN will be used to identify you precisely
  when it is necessary to 1) certify that you need to have access as
  indicated above or 2) determine that your access to such information is
  no longer needed. Although disclosure of your SSN is not mandatory,
  your failure to do so may impede the processing of such certifications
  or determinations, or possibly result in the denial of your being
  granted access to classified information.

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