Approved For Release 2001/03/07 : C'A-RDP96-00789Pt0)aq31001'§0_9 /,?OPO
    STATEMENT OF CONSENT
    1 6,4 @ZVIAI as a participant in the INSCOM
    GRILL FLAME Project (IGFP) do hereby give my consent IAW AR 381-17 to the
    tape recordingt 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 recordingsare 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
    individualt 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.
    WITNESS:
         z@&
    -Name, RankrGr de
         SGFOIA3
    Social Security Number
    S-190/ 909- ?, AA
    Unit/Organization
    Posilion
    SGFOIA3
    SIGNED:
         22A"a4z
    Name, Rank/Grad&
    Sociai becurity Number
    Uff " 6-,USO
    @nit/Organization
    Position 9Z
    Approved For Release 2001/03/07 CIA-RDP96-00789ROO2100150012-0