MEMORANDUM FOR RECORD

SUBJECT:  Personal Attestation upon the Granting of Security Access 

1.  In accordance with DoD 5200.1-PH-1, all DoD military members and civilian employees who have been granted a Top Secret clearance or granted access to a specially controlled access category or compartment must make a verbal attestation.

2.  “I ACCEPT THE RESPONSIBILITIES ASSOCIATED WITH BEING GRANTED ACCESS TO CLASSIFIED NATIONAL SECURITY INFORMATION. I AM AWARE OF MY OBLIGATION TO SAFEGUARDING AND LIMITING ACCESS TO INDIVIDUALS WITH THE PROPER SECURITY CLEARANCE AND OFFICIAL NEED TO KNOW.  I FURTHER UNDERSTAND THAT IN BEING GRANTED ACCESS TO CLASSIFIED INFORMATION, A SPECIAL CONFIDENCE AND TRUST HAS BEEN PLACED IN ME BY THE UNITED STATES GOVERNMENT.”

     	
(Date)	
I attested to the statement above on

 

Signature of Individual	
	
Signature of Witness	

     	
Printed Name of Individual	
	.	
Printed Name of Witness