JERK Act 6 | JFK Act 6 WW 55157 DocId: 32404520 Page 66
RETIREMENT AND- RESIGNATION EXIT COVER BRIEFING NAME (Last, first,middle) 4 7 , oo STAFF OR DIVISION lWWHITTen A Wess I Filors & STEP, soci ay “ A GRADE GS x AGENCY EOD RESIGNATION DATE(S): perry 920 AGENCY JOB TITLE RETIREMENT SF-2801 | ATTACHED $e L | Last workin H CIA EMPLOYMENT HISTORY INCLUDING OVERT PERIODS (inelude both domestic and overseas OATE assignments) ° AREA OF ASS LGNMENT . i T oe | COVER NOMINAL DATE USED OBSOLETE PREVIOUS an 2554 EDITIONS ,-! . SEGRE snot 1 (4 9-12-21) EXCLUDED Pry mae HW 55157 DBocld:324045270 Page 67
FUTURE EMPLOYMENT PLANS re L GOVERNMENT =< NONGOVERNMENT OTHER (speci fy) RETIREMENT FOREIGN TRAVEL PLANS SENSITIVE. SPECIAL, OR COVERT SITE ASSIGNMENTS OTHER (specify) List RELATIVES EMPLOYED BY CIA , ‘ CIA AWARDS | MEDALLION | | CERTIFICATE OF DISTINCTION | INTELLIGEN M GENCE MEDAL LENGTH OF SERVICE CERT. 1 i | EMPLOYEE HAS BEEN DECLARED COMPROMISED CREDIT BUREAU RECORDS INDICATE AGENZY | NONAGERCY - . EMPLOYEE HAS NOT BEEN DECLARED OR COMPROMISED . : . Los Ar~f | ff cms fi COVER BRIEFING | } | | | E | ACKNOWLEDGE AGENCY EMPLOYMENT FOR COMPLETE PERIOD OF ASSIGNMENT 00 NOT ACKNOWLEDGE AGENCY EMPLOYMENT. USE INSTRUCTIONS AS OUTLINED BELOW ZN ACKNOWLEDGE PARTIAL AGENCY EMPLOYMENT AS INDICATED BELOW THE EMPLOYMENT HISTORY ON PAGE 1 1S ‘THE ACTUAL DESCRIPTION OF SERVICE. THE EMPLOYMENT HISTORY SELOW 1S THE COVER STORY CONTRIVEO FOR USE AFTER DEPARTURE FROM AGENCY EMPLOYMENT. AREA TYPE OF OVER ; ; OF ASSIGNMENT COVER ¢ ORGANIZATION JOB TITLE HW, 55157 DBocld:324045270 Page 686
= TYPE MSALTH INSURANCE CARD (SSUED y LIFE {INSURANCE Wile CON WERT fwree NOT CONVERT | DEPARTING EMPLOYEES ACKNOWLEDGEMENT tI acknowledge that I have been briefed by the Central Cover Staff on the date noted below and do understand that I will be as an employee of the Central Intelligence Agency from the date I entered on aguty through the cate of departure in accordance with instructions as outlined above. have been informed as to the employment references applicable in my case. IS July 4 Jo. REMARKS JFK Act 6 (1) (A) iJEK Act 6 (1) (B) COORDINATION ccs/ocm " m ccs/ocs | ’ }ces/oco : CCS/NC ——__ Po | FINAL APPROVING AUTHORITY HW 55157 Docld:32404520 Page 69
- on a _ FO°78 ot SECURITY REMINDER 7 Ohme., I, , have been reminded that, “by virt ue “Of my duties with the Central Intelligence Agency, I have been the recipient of classified information and information concerning intelligence sources and methods, and that my Entrance on Duty Secrecy Agreement requires me to pro- tect such data. Moreover, I have been given an opportunity to review my Entrance on Duty Secrecy Agreement. 2. I have also been reminded that I am not permitted to retain any documents or other materials which are the property of the CIA or the custodial responsibility of CIA, and I affirm that I do not have in my possession, nor am I taking away from CIA any such documents or materials. 3. Finally, I am aware of my responsibility to notify the _CIA promptly in the event I am called upon by properly constituted authorities to testify or provide information that I am pledged not to disclose and I will advise said authority of my secrecy agreement. ‘and request that my obligation to testify be established before r am required to do so. Witness: Date FORM OBSOLETE PREVIOUS £2.77 5 COITIONS HW 55157 DBocld:324045270 Page 71
\ [ SECRECY AGREEMENT Io, (print full name), hereby agree to accept as a prior condition of my being employed by, or otherwise retained to perform services for, the Central Intelligence Agency. or for staff elements of the Office of the Director of Central Intelligence (hereinafter collectively referred to as the “Central Intelligence Agency”) the obligations contained in this agreement. - 2. [understand that in the course of my employment.or other service with the Central Intelligence Agency I may be given access to information which is classified in accordance with the standards set forth in Executive Order 12065 as amended or superseded, or other applicable Executive Order, and other information which, if disclosed in an unauthorized manner, would jeopardize foreign intelligence activities of the United States Government. I accept that by being granted access to such information I will be placed in a position of special confidence and trust and become obligated to protect the information from unauthorized disclosure. 3. In consideration for being employed or otherwise retained to provide services to the Central Intelligence Agency, hereby agree that I will never disclose in any form or any manner any of the following categories of information or materials, to any person not authorized by the Central Intelligence Agency to receive them: a. information which is classified pursuant to Executive Order and which I have obtained during the course of my employment or other service with the Central Intelligence Agency; b. information, or materials which reveal information, classifiable pursuant to Executive Order and obtained by me in the course of my employment ‘or other service with the Central Intelligence Agency but which, because of operational circumstance or oversight. is not formally marked as classified in accordance with such Executive Order and which | know or have reason to know has not been publicly acknowledged by the Agency: c. information obtained by me in the course of my employment or other service with the Central Intelligence Agency that identifies any person or organization that presently has or formerly has had a relationship with a United States foreign intélligence organization, which relationship the United States Government has taken affirmative measures to conceal. 4. I understand that- ‘the burden will be upon me to learn whether information or materials within my control are ’ considered by the Central. ‘Intelligence Agency-to fit ‘the descriptions sét forth in paragraph 3; and whom the Agency has authorized to receive it. 5. As a further condition of the special confidence and trust reposed in me by the Central Intelligence Agency, | hereby agree to submit for review by the Central Intelligence Agency all information or materials including works of fiction which contain any mention of intelligence data or activities, or contain data which may be based upon information classified pursuant to Executive Order, which I contemplate disclosing publicly or which I have actually prepared for public disclosure, either during my employment or other service with the Central ‘Intelligence Agency or at any time thereafter, prior to discussing it withior showing it to anyone who is not authorized to have access to it. [ further agree that I will not take any steps toward public disclosure until I have received written permission to do so from the Central Intelligence Agency. : JI understand thar the purpose eof the review described in paragraph 5 is to give the Central Intelligence Agency an opporiunity to ae tha hg png the information or materials. which I contemplate disclosing publicly contain any information which I have-agieed: ‘not to disclose. I further understand that the Agency will a act upon the materials I submit and make a response_to. ‘me; er yithinrs easonable time.. : Mg ee 7. 1 understand that all ‘information or materials which I may. ‘acquire in the coiitse ‘of | my employment or other service with the Central Intelligenée Agency which fit the descriptions set out in paragraph 3 of this agreement are and will remain the property of the United States Government. I agree to surrender all materials “reflecting such information which may have come into my possession or for which I am responsible because of my employment or other service with the Central Intelligence Agency, upon demand by an appropriate official of thé Central Intelligence Agency, or upon the conclusion of my employment or other service with the Central Intelligence Agency. 8. I agree to notify the Central Intelligence Agency immediately in the event that I am called upon by judicial or congressional authorities to testify about, or provide, information which I have agreed herein not to disclose. 9. [ understand that nothing contained in this agreement prohibits me from reporting intelligence activities which I consider to be unlawful or improper directly to the Intelligence Oversight Board established by the President or to any successor body which the’ ‘President may establish. I recognize that there are also established procedures for bringing such matters to the attention of the Agency*Inspector General or to the Director of Central Intelligence. | further understand ‘that any information which I may report to the Intelligence Oversight Board continues to be subject to this agreement for all other purposes and that such reporting does not constitute public disclosure or declassification of. that information. FORM OBSOLETE PREVIOUS 7 979 368 — Epitons HW 55157 DBocld: 324045270 Page 72
SECRECY AGREEMENT I, understand that by virtue of my duties in _ the Central “Intelligence Agency, I may be the recipient of information and intel- ligence which concerns the present: and future security of the United States and a which. belongs:.to. the United States. This information and intelligence, together 7 ' with the methods of collecting and handling it, are classified according to security standards set by the Central Intelligence Agency. I have read and under- stand the provisions of the Act of Congress of June 15, 1917 (Espionage Act), as amended, concerning the disclosure of information relating to the National Defense and I am familiar with the penalties provided for violation thereof. 2. I. agree that I do not’ now, nor shall I ever possess any right, interest, title or claim in or to any of the information or intelligence or the methods of collecting or. handling of it which has come or shall come to my attention by virtue of my. connection with the Central Intelligence Agency, but shall always recognize the property right of the United States of America in and to such: matters. | 3. I do solemly swear that I will never divulge, publish nor reveal either by word, conduct, or by any other means such classified information, intelligence or knowledge, except in the performance of my official duties and in accordance with the laws of the United States, unless specifically authorized in writing in each case by the Director of Central Intelligence. , = AL ‘I understand that. no change in my assignment or employment will relieve i me of my obligation under this oath and that the provisions of this oath will | | Yemain binding upon me even after the termination of my services with the United States. | . v4 5. I understand that my employment by the Central Intelligence Agency is conditioned upon my understanding of and strict compliance with "Security Regula- tions CIA", and the appendices thereto. , 6. I take this obligation freely, without any mental reservation or pur- pose of evasion. In witness whereof I have set my hand and seal this hay ot LeLeuatis 19 SS JER AGT 6-2-4} JEK “Act 6 (1) (B) Witnessed by me thie / day of ‘ 19_§3 a WASHINGTON, D, £, FORM MO. Oct 1959 28-33 HW 55157 DBocld:324045270 Page 73
RETIREMENT AND RESIGNATION EXIT COVER BRIEEIN a. A Last, First, Middle) CC Tis a XI Stare we | SEK Act 6 (1) (A) i OVERT S COVERT JFK Act 6 (1) (B) i ‘ SEPARATION DATE fase WORKING DAT ag / JO _ 2/29fvo RETIREMENT RESIGNATION | apa LEAVE ‘. Lae Rica CJ cse Cjcia J ese SIE OE SETUON | SATE Ol FUTURE EMPLOYMENT PLANS OVERSEAS : | NON GOVERNMENT REIGN- TRAVEL PLANS ; ; ; _ NNT pee ae H ~ : Dobe : L ' i Z NSETIVE, SPECIAL, OR COVERT SITE ASSIGNMENTS ‘ EMPLOYEE HAS NOT BEEN DECLARED OR COMPROMISED EMPLOYEE HAS “BEEN |_| vectareo | _s[_ compromisen (specify) - BACKSTOPPING #§S NECESSARY GIVE REASON COVER BRIEFING ACKNOWLEDGE AGENCY EMPLOYMENT FOR COMPLETE PERIOD OF ASSIGNMENT | D0 NOT ACKNOWLEDGE AGENCY EMPLOYMENT, FOLLOW INSTRUCTIONS OUTLINED SELOW — Le ACKNOWLEDGE PARTIAL AGENCY EMPLOYMENT AS INDICATED BELOW ‘E EMPLOYMENT HISTORY BELOW 1S THE COVER STORY CONTRIVED FOR USE AFTER: SEPARATION FROM THE AGENCY. Date AREA TYPE OF ‘ FROM ro OF ASSIGNMENT COVER COVER ORGANIZATION JOR TITLE ! USE PREVIOUS : > (4-9-12-21) 2554 vee meevious SEGRE HSH = [E2, imPver CL. ay: 011180 HW 55157 Docld:32404520 Page T4
BLOCK KECORDS tN OFFICE OF PERSONNEL BLUCK CREDIT RECORDS BLOCK TELEPHONE LOCATOR RECCROS !.0. CARO | PREPARE ISSUE : oe 4 x ORM 1551 TYPE: 2) Fong ey) MISCELLANEOUS FOLLOW-UP ACTION TO BE JFK Act 6 (1) (A) co ' WJEK Act 6 (1) (B) TAKEN BY COVER OFFICER EFFECTIVE OQATE YES NO ix pes] | EOD / Ab Ss? a EFFECTIVE DATE , 1YES | NO x | Eo? i YES NO an EoD HOSPITALIZATION INS. CARD TYPE: AG. INFORMATION PERTAINING TO DEPARTING EMPLOYEE !F EMPLOYEE HAS APPLIEO FOR NEw EMPLOYMENT PRIOR TO CONTACTING CCS WHAT EMPLOYMENT REFERENCE WAS USED? suasect | X | was i #taAS NOT RETURNED ALL COVER DOCUMENTATION. IDENTIFY OOCUMENTS THAT HAVE NOT BEEN RETURNED. RELATIVES, EMPLOYED BY CIA (name and relationship) ond : DEPARTING EMPLOYEES ACKNOWLEDGEMENT I certify that i have been briefed by the Central Cover Staff on this date and I understand that: ! -| I will be acknowledged as an employee of the instructions set forth in the accordance with the Central Intelligence Agency in Cover. Briefing Section above. XK I will not te acknowledged as an employee of the Central Intelligence Agency. i have been informed of the employme 2 LE Dh DAT REMARKS JEK CcCS/OCB/M ccs/oce/s SIGNATURE Rehticnint adértse i GPK Act 6 (1) (A) JFK Act 6 (1) (B) . a F-O03-YO SG Cinco COORD !NAT!ON ccs/ccs ccs/csB HW 55157 DBocld:324045270 Page 75 COMPONENT ces/€ 7- 2-28~§b
* DEC @7 ’S5 11:54AM oo : P.373 ° SECRECY AGREEMENT De Dg ce a (print full name), hereby agree to accept as a prior condition of my being employed by, or otherwise retained to perform services for. the Central Intelligence Agency, or for staff elements of the Director of Central Intelligence (hereinafter collectively referred to as the ‘‘Central Intelligence Agency’’), the obligations contained in this agreement. 2.1 understand that in the course of my employment or other service with the Centra Intelligence Agency I may be given access to information or material that is classified or is in the process of a classification determination in accordance with the standards set forth in Executive Order 12356 as amended or superseded, or other applicable Executive order, that if disclosed in an’ unauthorized manner would jeopardize intelligence activities of the United States Government. I accept that by being granted access to such information or material I will be placed in a position of special confidence and trust and become obligated to protect the information and/or material from unaushorized disclosure. 4. In consideration for being employed or oth ryise gatainggd top ovide services to the Central Intelligence Agency, I hereby agree that I will never disclose in any form ¢r-m ennette-eay person not authorized by the Central Intelligence Agency to receive it, any information or material in either aKinef a. information or material received or obtaihed Intelligence Agency that is marked as classified br thhy I kn@w is/classified; coupge of my employment or other service with the Central Intelligence Agency that I know is in the process of aclassjfication determination. , 4, I understand that it is doy responsibility to consult with appropriate managements thorities in the component or av yejained my services, or with the Central Intelligence 4 ‘4's Publications Review Board genethted with the Agency, in order to ensure that I knQy Nether information or material axe reason to believe might be in either of, jes sé paragraph 3 is PMO fit in either of those categoris : considered by the Cenths perce A receive such information et at oe 5. As a further cond csp Sci by agree to submit for revie@™by_{ work of fiction, which contaitrany | Regnescuay WENGE oF A fata or ac vitdesQe céntai ang cia pformation or material that might be based upon either ofthe ca fat contemplate/ disclosing publicly or that I have actually prepared for public ¢ scteculs otter service With the-Ceftral Intelligence Agency or, at any time thereafter, prior IPatseaskingyt Sho is notlautharjsed-tottave access to the categories set forth in paragraph 3. 1 fugther-a] BREA Et som wart public isa osure-titil | have received written permission to do als off the ree . ; Oo 6. I undegs ite the p ups 9 dae described in paragraph. GORE entral Inte sence Agency an Sra hether the/informp co as g-publicly zhnfains any information wiityact uporyprip submsyon an make a , . ray opportunity to Gays) + i eas eed not to 2 on rpher ‘ab tand that the os A'S furs P xtion on the basis 2 or material that ay - : : Vt Ge et gel : response to me With dSonable time. nders} acs 7 cre the Prgency’s inittal deter that the informa Seem fm ‘Y Ay) question deni ek are sourdes, { may be called upory jo le fjéally identify such sources. My failure prrekitaDsidx0 may by/itse result in deni of permisaigh da publish or othe ise dfeclose the information or material aise Daye OF ait |! | a7 [LASS wi Za era in Eh ea rr oe ay dace Reda Tye ce wi . nderstancftiiat aly hpormnarjon or Tat adi thataemay ‘ecerreé i theyep or riy amp oyment or other service with the Central Intelligence Agencyshat figdeither of the afégories sex.forth in paragraph Z-6F this agreement are and will remain the property of the United ‘States Gov ti unless ige determi ing of Appropriate official or final ruling Gy) of a court of law. I agree to surrender ing consytuth ing OKreflecti Fonct formation or material upon demand by an appropriate official of the Centra] Mrelligence_Age oon the conclusion of my’employment or other service with the Central Intelligence Agency. 8. I agree to notify the Central Intelligence Agency immediately in. the event that [ am called-upon by judicial or con- gressiona! authorities, or by specially established investigatory bodies of the executive branch, to testify about, or provide, in- formation or material that I have agreed herein not to disclose. In any communication with any such authority or body, I shall observe all applicable rules or procedures for ensuring that such information and/or material is handled in a secure manner. 9. I understand that nothing contained in this agreement prohibits. me from reporting intelligence activities that 1 con- sider to be unlawful or improper directly to the Intelligence Oversight Board established by the President, or to any successor body that the President may establish, or to the Select Committee on Intelligence of the House of Representatives or the Senate. _ T recognize that there are also established procedures for bringing such matters to the attendon of the Agency's Inspector General or to the Director of Centra! Intelligence. In making any report referred to in this paragraph, I will observe all applicable rules or procedures for ensuring the secure handling of any information or material that may be invoived.-1 understand that any such information or material continues to be subject to this agreement for all other purposes and that such reporting does not constitute public disclosure or declassification of that information or material. 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“10. I understand that any breach of this agreement by me may result in the Central Intelligence Agency taking admin- istrative action against me, which can include temporary loss of pay or termination of my employment or other service with the Central Intelligence Agency. I also understand that if I violate the terms of this agreement, the United States Government may institute a civil proceeding to seek compensatory damages or other appropriate relief. Further, I understand that the disclosure of information that I have agreed herein not to disclose can, in some circumstances, constitute a criminal offense, ~ 11. T understand that the United States Government may, prior to any unauthorized disclosure that is threatened by me, choose to apply to any appropriate court for an order enforcing this agreement. Nothing in this agreement constitutes a waiver on the part of the United States to institute a civil or criminal proceeding for any breach of this agreement by me. Nothing in " this agreement constitutes a wavier on my-part of any possible defenses I may have in connection with either civil or criminal proceedings that may be brought against me. 12. In addition to any other remedy to which the United States Government may become entitled, I hereby assign to the United States Government all rights, title, and interest in any and all royalties, remunerations, and emoluments that have resulted or will result or may result from any divulgence, publication or revelation of information or material by me that ls carried out in breach of paragraph 5 of this agreement or that. involves information or material prohibited from disclosure by the terms of this agreement. , 13. T understand and accept that, unless I am provided a written release from this agreement or any portion of it by the Director of Central Intelligence or the Director's representative, all the conditions and obligations accepted by me in this agree- ment apply both during my employment or other service with the Central Intelligence Agency, and at all times thereafter. 14, [understand that the purpose of this agreement is to implement the responsibilities of the Director of Central Intel- ligence, particularly the responsibility to protect intelligence sources and methods, as specified in the National Security Act of 1947, as amended. 15, These restrictions are consistent with and do not supersede conflict with or otherwise alter the employee obligations rights or liabilities created by Executive Order 12356; section 7211 of title 5, United States Code (governing disclosures to Congress); section 1034 of tide 10, United States Code, as amended by the Military Whistleblower Protection Act (governing disclosure to Congress by members of the Military); section 2302(b)(8) of ttle 5, United States Code, as amended by the Whistleblower Protection Act (governing disclosures of illegality, waste, fraud, abuse or public health or safety threats); the Intelligence Identities Protection Act of 1982 (50 U.S.C., 421 er seq.) (governing disclosures that could expose confidential Government agents), and the statutes which protect against disclosure that may compromise the national security, including section 641, 793, 794, 798, and 952 of title 18, United States Code, and section.4(b) of the Subversive Activites Act of 1950 (50 U.S.C. section 783(b)). The definitions, requirements, obligations, rights, sanctions and liabilities created by said Executive Order and listed statutes are incorporated into this Agreement and are controlling. 16. I understand that nothing in this agreement limits or otherwise affects any provision of criminal or other law that may be applicable to the unauthorized disclosure of classified information, including the espionage laws (sections 793, 794 and 798 of Title 18, United States Code) and the Intelligence Identities Protection Act of 1982 (P.L. 97-200; 50 U.S.C., 421 er $eq.). 17. Each of the numbered paragraphs and lettered subparagraphs of this agreement is severable. If a court should find any of the paragraphs or subparagraphs of this agreement to be unenforceable. I understand that all remaining provisions will continue in full force. 18. I make this agreement in good faith, and with no purpose of evasion. 19, This agreement shall be interpreted under and in conformance with the law of the United States. Signature Date The execution of this agreement was witnessed by the. undersigned, who accepted it on behalf of the Central Intelligence Agency as a prior condition of the employment or other service of the person whose signature appears above. WITNESS AND ACCEPTANCE: Signature ; Pa HW 55157 DocId: 32404520 Page Tf?