STATEMENT OF CONSENT

• Document Type: CREST
• Collection: STARGATE
• Document Number (FOIA) /ESDN (CREST): CIA-RDP96-00789R002100150010-2
• Release Decision: RIPPUB
• Original Classification: S
• Document Page Count: 1
• Document Creation Date: November 4, 2016
• Document Release Date: December 4, 1998
• Sequence Number: 10
• Publication Date: April 22, 1980
• Content Type: CONT

Approved For Release 2001/03/07 :CIA-RDP96-00789~0~~1000 ~~~,lj~ ~~~
STATEMENT OF CONSENT
I ~ u-~~EP~I G+J. ~tjC~O,cI,~AGL,~- as a participant in the INSCOM
GRILL FLAME Project (IGFP) do hereby give my consent IAW AR 3E31-17 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.Q. 9397, Numbering
System far .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. Mandatary or Uoluntary 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.
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Approved For Release 2001/03/07: CIA-RDP96-007898002100150010-2