PRIVACY ACT STATEMENT
AUTHORITY: 70 U.S C BOis. 44 U.S.C 3101. and EO 9397
PRINCIPAL PURPOSES: usea to record informatron ana aetarls of crtmmalactMty which may requtre mvestrgatrve actron by commanaers. supervtso•.
secumy poltee. AFOSI speetal agents, etc. Usea to provlfh mformatlon to the approprtate rndrvidulls wrthm DOD organrzatrons who ensurE' th,u
proper legal and admmrnratrve action is taken
ROUTINE USES: Information may~ drsclosed to local. county. state and federal law enforcement or rnvestrgatory authorttres lot mvest•gatron .• nd
possrble mm•nal prosecution or Civil coun act ron Information extracted from th•s form may~ used mother related crtmmal andtot CIVIl proceedmgs
DISCLOSURE IS VOLUNTARY: SSN is used to positively r!Jentlfy the rndivrdual makrng the statement and as a condurt to check past mmmal activit)
records
SECTION IV. STATEMENT
THIS PAGE USED FOR SIGNATURE ONLY. TEXT OF STATEMENT BEGINS ON PAGE 3-----------------7
ily And of m11 own free will make this stAtement without hAving been subjected to any coercion, unlawful influence, or unlawful
(o affirm)/ have read this statement, initialed all pages and co ions, and it is true c to the best of my knowledge. •
21st day of _.J...u...l..,y______ 19 94
Use pia on bond paper (both sraes optional). At the top right of each l"'ge. print or type: "(Last Name of lnd1111aua1 makmg the StatE-ment} on (Oatt')."
At the bottom of each page, print or type: "Page__ of_._ Pages . The individual must initial the top and bottom entries and sign his/her name at
the bottom of each page.
AF form 1168, JUN 91 (REVERSE) ·u.s.a-rmorotPIIntlngOI/IOI: 1•1- 211-461~131 Page~ 2._ Pages