Approved For Release 2001/03/67 : CIA-RDP96-00@ /I ON05P?P-3
        DATE
        STATEMENT OF-CONSENT
        4@Wkft-ve'li- cT as a partiCiDanL in the INSCOM
        GRILL FLAME Proje( n_G_F_`P do hereby gi've- 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 abo ve-, 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 participant
        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, No ember 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, andthe 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:
        Name, Rank/Grade
        Social Security N=6@Tr___
        a5;@Illvr5 CC"I-A
        Unit/Organization
             -e "t-
        7
             , 11 A/J IVI'04, S
        FOSM6,
             SGFOIA3 SIGNED:
        SGFOIA3 ame, RaZ/Grade
        Social Security Number
        Cl,,D CpAltI6
        Unit/Organization
        A14 "il
           I
        osi
        on
        Approved For Release 2001/03/07 : CIA-RDP96-00789ROO2100150055-3