Form appears to be notice to an unidentified agent that an official administrative inquiry regarding possible misconduct or improper performance of official duties is underway.
FD-645 (Rev g-11-03)
WARNING AND ASSURANCE TO EMPLOYEE REQUIRED TO PROVIDE INFORMATION
This is an official administrative inquiry regarding possible misconduct or the improper performance of official duties In accordance with the Privacy Act of 1974, you are advised that the authority to interview you or otherwise obtain a written statement from you is contained in Title 28, Code of Federal Regulations, Section 0 85(c)
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This inquiry pertains to an allegation 11204
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!State the general nature of the inquiry)
For purposes of this inquiry, you may be interviewed, asked to provide a written statement, or both, and the information you provide will assist in determining whether administrative action is warranted You have a duty to participate in an interview or to provide written statements, and you can expect to be dismissed from the rolls of the FBI if you refuse to do so, or if you fail to respond fully and truthfully in any answers or written account you provide
Neither your statements nor any information or evidence gamed by reason of your statements can be used against you in any criminal proceeding, except that if you knowingly and willfully provide false statements or information, you may be subject to criminal prosecution for that action
Pursuant to the Privacy Act, this information is being sought for the purposes of an agency disciplinary proceeding The information itself and any information or evidence resulting therefrom may be used in the course of this proceeding, which could result in disciplinary action, includmg dismissal Information may be disclosed to other federal agencies for a law enforcement purpose, to employees of the Department of Justice m the performance of official duties, to the Judicial Branch of the Federal Government in response to a specific request or otherwise where disclosure appears relevant to the authorizedfunction of the recipient judicial office or court -system, and to an adjudicative body, such as the Equal Employment Opportunity Commission and the Merit Systems Protection Board, when the United States, the FBI, or its employees, in an official capacity, are parties to or have an interest in the litigation, and such records are determined by the FBI to be relevant to the litigation Disclosure may also be made m accordance with all applicable routine uses published in the Federal Resister for the FBI's Central Records System (JUSTICEIFBI-002) and the Blanket Routine Uses Applicable to More Than One FBI System of Records (JUSTICEIFBI-BRU)
ACKNOWLEDGMENT
I have read and understand my rights and obligations as set forth above
Signature of Department of Justice Official Employee's Signature
Conducting Inquiry
Witness" Date
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PAT : 4 - 415-L.
DETAINEES-2343
DOJFBI-002871