PART 2; SEPARATING EMPLOYEE/CONTRACT EMPLOYEE CERTIFICATION

In accordance with DOJ Orders 2120.3C, 2400.3Aand OOJ Polley statement 0801 .02, I certify that:

d1 have discussed the sta1Us of au pending work matters with my supervisor. I}-
□ I have obtained an exit briefing from Departmental Ethics Office, If required. (OOJ Employees onlY) (202-514-8196), /I./J
O I/ _
ve obtained debriefing from SEPS If I had access lo NSI/SCI (202-514-3738). ;V/ ff
o1 have surrendered an Goverrvnent owned property, inciudlng Government-owned vehicles, computers, laptops. iPads/tablets,
!111d other Information technology equipment, ~rearms, ammunition, and other controlled property, such as cellular telephones,
pagers, office keys, unused transit subsidy passes, parking permits, uniforms and apparel.

D I have surrendered all passes, visas, officil¼l passports, specfal fde,11Jllfsatlon badges and ccedentlais, passwords , comblnalions,
etc., issued 111 connecllon\'lkti employment in the Component fl n LJ_
U I have returned ell Government-Issued travel, purcha.se, or fleet charge cards, and outstanding travel vouchers, etc. t,..J/ f .I .
D I hove returned all loaned matenals and audio visual equfpment includir1g books and, projectors, screens, !ape arid dlgilal /J j {r­
recorders!players, etc.

o4 returned an foderal records, classified documents-, $ensitive materials, file and desk keys, manuals and handbooks, etc.

~ v e not reMoved or destroyed any reoords, offlolal documents, and/or documentary materials from the Depa11ment ofJustice
1hat are expressly prohibited from removaVdestrucllon. I have obtain ed and submitted to the component's Records
Custodian/Manager the written approval of the Deputy Attorney General, Assistant Attorney General for Arlministrallon, or
COmponeol Head for !he removal of srry othernon-publlc documentation as required in Policy Statement 0801.02,

D I have llquldaled all debts owed to the Government for outstanding advances for travel, salary overpayments, leave, Imprest
ru11d, and other purposes; Including studenUoan repayment and se71c~; gr~ebJ.enls, such as training or allowance/bonus
agreements Or transfer orders requiring a period of seNlce /V., n
N r {1
0 I have furnished "t{tten explanation of the circumslanoes regard ing any accountable property !hat y.,as not returned or
cleared.
D I undersland lhal the depreciated value of Government property charged to me may be Withheld
theft or damage to such property Is delennlned to be due to negligence or intent on my part. / V)
ry,t,,~
1
me If lhe loss,

Date
b7 It./ /7

PART 3! RECORDS CUSTODIAN/MANAGER

fn accordan~ With Polley Statement 0801.02, I certify !hat

~ v e informed the emplcyeelcontracl employee about the prohibition on remolll~ or destroying any records, official
doaiments, arid/or documentary materials from the Department of Justice that are eXPressty prohibited from removal.

D The employee has obtained and has submitted to the Component's Records Officer/Manager, 1he wrflten approval of the

nor)-~~ bricinformation, as reqUired In Polley Statement 0801.02. fi)

Deputy Attorney General, Assistant Attorney General for Adminlsttallon, ·,r9e.mponent Head for the removai of ooples of other
/"1
o..:nie separating employee/oontracl emplcyee has Identified all DOJ records and non-records Within his/her possesaion and
control, lnduding the location of lhas.e records; and further, that the employee/conlract employee has removed personal
Information from DOJ Ines and segregated any-duplicates and reference materials for ilPProprlate disposition in accordance wlth
component policies for non·-record materials.

□ I have attached an c-x[8Jrlfun to the Exit Cle.arance Checklist for aM government property and lnfonna11on the! could not be
located or retrieved. N f1
Records c uet dlan I Recor --=:D;.::a:.:;
te::;.__ _ _ _ _ _.......
Signature ~··· ) · ,Y) '

SCO falt Clent'!lnce Ccrtificalion -Page 2 of3

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