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1561 28-00092 <br />2 <br />00371350000 <br />FORM D-~ SS3 U.S. DEPARTMENT OF COMMERCE <br />p-21-99- BUREAU OFTHE CENSUS <br />CONFIDENTIALITY AGREEMENT <br />NEW CONSTRUCTION PROGRAM <br />United States Census 2000 ~ ~' <br />1. Name of your Organization <br />2. Address (Number and Street RR HC, or Post Office Box Number) <br />P:O. Box 8181 <br />3. City, State, ZIP Code <br />4. Governmental Units Represented by your Organization <br />5. Name of your New Construction Program Liaison <br />6. Responsibilities of liaisons participating in New Construction program activities <br />New Construction program liaisons must agree to keep confidential the Census 2000 address information <br />they review or to which they have access. They may use this information solely for suggesting <br />improvements to the Census 2000 address list. All individuals from your organization who will be <br />reviewing Census 2000 addresses need to sign below to indicate they read and understand the Census <br />Bureau's rules on confidential information. These rules are provided in the New Construction Program <br />Confidentiality and Security Guidelines. In addition, liaisons who sign below indicate they have read and <br />understand the penalty for disclosing information obtained by the Census Bureau about addresses or <br />individuals is a fine of not more than 55,000, or imprisonment for not more than five years, or both. <br />Date Liaison's Signature and Printed Name <br />Telephone Number <br />11.1J26~;lQT- ~~ ~~~~- <br />(Primary New Construction Program Liaisonl <br />'CRAIG BENEDICT,PLANNING DIRECTOR <br />?sll~K~y9 gt ~n~~~-2,50.] <br />ROSCOE REEVE, Director. of Land Records Department <br />You may duplicate this form if you require more signature blocks <br />This form (Confidentiality Agreement, Participation Registration. and <br />Program Materials Request) must be returned by November 1,1999, <br />