DHS Form 11000-6 at a glance
What it is: Department of Homeland Security Non-Disclosure Agreement: you consent to the terms in consideration of being granted conditional access to information owned by, produced by, or in the possession of the United States Government.
Who signs: Sign on Signature: and enter the Date: to make this Agreement in good faith, without mental reservation or purpose of evasion. Under WITNESS:, enter the Typed/Printed Name, the Government/Department/Agency/Business Address and the Telephone Number, then Signature: and Date:.
A filled-in DHS Form 11000-6 example: a consultant signs with a witness
How to fill out DHS Form 11000-6, box by box
I, the Authorized Entity
After I, enter the individual official, employee, consultant, or subcontractor of or to the Authorized Entity, and write the Authorized Entity before (the Authorized Entity), intending to be legally bound.
Initials: the category of information
Acknowledge by placing your initials in front of the applicable category or categories of information that you may have access to, and your willingness to comply with the standards for protection.
Protected Critical Infrastructure Information (PCII) Initials: attest that you are familiar with, and will comply with all requirements of the PCII program set out in the Critical Infrastructure Information Act of 2002 (CII Act) (Title II, Subtitle B, of the Homeland Security Act of 2002, Public Law 107-296, 196 Stat. 2135, 6 USC 101 et seq.), as amended, the implementing regulations thereto (6 CFR Part 29), as amended, and the applicable PCII Procedures Manual, as amended.
Sensitive Security Information (SSI) Initials: attest that you are familiar with, and will comply with the standards for access, dissemination, handling, and safeguarding of SSI information as cited in this Agreement and in accordance with 49 CFR Part 1520, "Protection of Sensitive Security Information."
Other Sensitive but Unclassified (SBU) Initials: attest that you are familiar with, and will comply with the standards for access, dissemination, handling, and safeguarding of the information to which you are granted access as cited in this Agreement and in accordance with the guidance provided to you relative to the specific category of information.
Acknowledgement: your name, address and telephone
You have read this Agreement carefully and your questions, if any, have been answered.
Under Acknowledgement, enter the Typed/Printed Name, the Government/Department/Agency/Business Address and the Telephone Number.
WITNESS: name, address, telephone, signature and date
Under WITNESS:, enter the Typed/Printed Name, the Government/Department/Agency/Business Address and the Telephone Number, then Signature: and Date:.
More rules for DHS Form 11000-6
You represent and warrant that you have the authority to enter into this Agreement.
You acknowledge that you have received a security indoctrination concerning the nature and protection of information to which you have been provided conditional access, including the procedures to be followed in ascertaining whether other persons to whom you contemplate disclosing this information have been approved for access to it, and that you understand these procedures.
You will not disclose or release any information provided to you pursuant to this Agreement without proper authority or authorization.
You agree that you shall return all information to which you have had access or which is in your possession 1) upon demand by an authorized individual; and/or 2) upon the conclusion of your duties, association, or support to DHS; and/or 3) upon the determination that your official duties do not require further access to such information.
You shall promptly report to the appropriate official, in accordance with the guidance issued for the applicable category of information, any loss, theft, misuse, misplacement, unauthorized disclosure, or other security violation, you have knowledge of and whether or not you are personally involved.
Unless and until you are released in writing by an authorized representative of the Department of Homeland Security (if permissible for the particular category of information), all conditions and obligations imposed upon you by this Agreement apply during the time that you are granted conditional access, and at all times thereafter.
Signing this Agreement does not bar disclosures to Congress or to an authorized official of an executive agency or the Department of Justice that are essential to reporting a substantial violation of law.
If you violate the terms and conditions of this Agreement, such violation may result in the cancellation of your conditional access to the information covered by this Agreement.
If you violate the terms and conditions of this Agreement, you could be subjected to administrative, disciplinary, civil, or criminal action, as appropriate, under the laws, regulations, or directives applicable to the category of information involved and neither the United States Government nor the Authorized Entity have waived any statutory or common law evidentiary privileges or protections that they may assert in any administrative or court proceeding to protect any sensitive information to which you have been given conditional access under the terms of this Agreement.
Sources
[1] DHS Form 11000-6 (10/18), Department of Homeland Security Non-Disclosure Agreement (the Official source link on this page).