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APPENDIX F
PRIVACY ACT OF 1974
ADVISEMENT STATEMENT
US Army Intelligence is conducting an investigation of a counterintelligence matter, pursuant to Army regulations, which necessitates obtaining personal information from you. The Privacy Act of 1974, requires that each individual asked to provide personal information be advised of the following four points:
a. AUTHORITY. The Department of the Army (DA) is authorized to conduct counterintelligence investigations under Executive Order 10450, "Security Requirements for Government Employees," Executive Order 12333, "United States Intelligence Activities," and Title 10, United States Code, Section 3012.
b. PRINCIPAL PURPOSES: This investigation is being conducted by the Army to permit the responsible official(s) to determine the nature and extent of action, if any, necessary to ensure the security of the Army. The principal objectives in collecting this information are:
(1) To acquire factual information and/or evidence pertinent to the matter under investigation.
(2) To determine facts concerning possible compromise of US National Defense Information.
c. ROUTINE USES. The information obtained from you will become part of Army records and will be provided to those officials responsible for the security of the Army. The information may, at Army initiative or upon request, be furnished to accredited Department of Defense activities, other Federal agencies, and/or to law enforcement agencies for their official use. Under certain circumstances, pursuant to applicable international agreements, the information may be provided to security and/or law enforcement officials of a foreign government.
d. VOLUNTARY OR MANDATORY NATURE OF DISCLOSURE. The disclosure of personal information is voluntary. However, failure to disclose necessary and relevant information which impedes the investigation may have an adverse impact on your security clearance, if you possess or are being considered for one, or your employment, if you are a military member or employee of the Department of the Army.
SIGNATURE____________
DATE_________________
DA FORM xx-R
