STATEMENT OF CONSENT

• Document Type: CREST
• Collection: STARGATE
• Document Number (FOIA) /ESDN (CREST): CIA-RDP96-00789R002100150012-0
• Release Decision: RIPPUB
• Original Classification: S
• Document Page Count: 1
• Document Creation Date: November 4, 2016
• Document Release Date: December 4, 1998
• Sequence Number: 12
• Publication Date: April 22, 1980
• Content Type: CONT

Approved For Release 2001/03/07 : CIA-RDP96-00789F9ag31001.?0,91~
STATEMENT OF CONSENT
I, /4?,44/14Afp / 7,4ZVI' as a participant in the INSCOM
GRILL FLAME Project (IGFP) do hereby give my consent IAW AR 381-17 to the
tape recording, monitoring and transcribing of all session interviews
conducted as an integral part of the IGFP. I understand that all of my
session interviews are tape recorded. I further understand that these
tape recordings.are subject to being monitored and/or transcribed by third
parties not otherwise involved in the session interviews.
In conjunction with my consent to the above, I also waive any claim or right
of ownership to all tape recordings, and transcripts made, or which have been
made, in conjunction with IGFP. I understand that these tape recordings
and transcripts are the property of the United States Government.
I execute this written consent to formalize my previous verbal consent to the
above; having given my verbal consent to the above when I became a partici-
pant in the IGFP.
DATA REQUIRED BY THE PRIVACY ACT OF 1974
(5 U.S.C. 552a)
1. Authority: National Records Act, 44 U.S.C. 3102; E.O. 9397, Numbering
System for Federal Accounts Relating to Individual Persons, November 22, 1943.
2. Principal Purpose: To maintain a record of those individuals who have
consented to the recording, monitoring or transcribing IGFP. session interviews.
3. Routine Uses: The Social Security Number is to be used to identify the
individual, and the information is to be retained strictly. within the Program.
4. Mandatory or Voluntary. Disclosure: Information is disclosed on a voluntary
basis, but withholding information will render it impossible to grant an
individual access to or participation in the Program.
Name, Rank Grade
SGFOIA3 MEN Social Security um er
9--r'1z
sco, 909--r,
Unit/Organization
Position
SGFOIA3
Name, Rank/Grads
6S-12-
1,416 CT'W
Unit/Organization
Approved For Release 2001/03/07 : CIA-RDP96-00789R002100150012-0