Opening statement
The employee's name, typed or printed, and the definitions of employment and separation.
OF109
Separation Statement
- Agency
- GSA
- Revision
- Rev. 09/1994
- Fillable fields
- 12
- Pages
- 1
- Official source
- GSA form page
- Checked
- October 20, 2026
Optional Form 109 (OF 109): Separation Statement
Optional Form 109 (OF 109), Separation Statement, is a one-page statement marked STATE-USIA at the top and bottom. An employee makes it in connection with separation from employment, and its text refers to the Department of State and the United States Information Agency (USIA). The footer prints OPTIONAL FORM 109 and 994, and GSA's page gives a current revision date of 09/1994. GSA hosts a copy in its forms library.
The form says employment includes all periods of assignment or detail and any temporary, part-time or intermittent employment, and separation includes suspension for any period in excess of 30 days, retirement from active duty, transfer to another agency, resignation and furlough to enter military service. In six numbered paragraphs the employee states that documents were surrendered, that classified information will not be revealed, and that the interviewing officer explained the criminal penalties listed.
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What's on OF 109
Paragraphs 1 and 2: documents surrendered
Classified or administratively controlled documents and material, including diaries and memorandums of conversation that contain such information, and unclassified documents relating to official business.
Paragraph 3: no disclosure
A statement that classified or administratively controlled information, or information received in confidence, will not be published or revealed except as authorized by officials of the employing Department or Agency.
Paragraph 4: penalties listed
Sections of Title 18, Title 50 and Title 42 of the U.S. Code, and a statement that these restrictions do not supersede, conflict with or otherwise alter rights created by Executive Order 12356 and the other laws it lists.
Paragraph 5: reaffirmation and debriefing
The employee reaffirms that the espionage laws were made available and classified information was returned, and strikes out have or have not to show whether a security debriefing was received.
Paragraph 6 and signatures
Notice of the criminal penalties in Section 1001 of Title 18, United States Code, then the signature blocks for the interviewing officer and the employee.
How to complete OF 109
- 1
Enter the name
Type or print the employee's name in the opening line, as the form asks.
- 2
Read paragraphs 1 to 6
Each paragraph is a statement about documents, disclosure or penalties. Paragraphs 4 and 6 say the interviewing officer advised the employee of the penalties.
- 3
Mark the debriefing
In paragraph 5, the form says to strike out have or have not to show whether a security debriefing was received.
- 4
Employee signs
The employee signs on the line marked Signature in Presence of Interviewing Officer and adds date of birth, date signed, typed name and other names used.
- 5
Officer signs
The interviewing officer signs and dates the form and adds a typed name and post, department or agency.
These steps follow the form's printed blocks.
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Where it goes and what the form says
Where it goes
The form prints no address or routing. It is signed in the presence of the interviewing officer, who adds a post, department or agency.
Laws listed
Title 18, U.S. Code Sections 641, 793, 794, 798, 952, 1905 and 2071, Title 50, U.S. Code Section 783 (b) and 783(d), and Title 42, U.S. Code Sections 2272 to 2277.
Reporting attempts
Paragraph 5 says attempts by an unauthorized person to solicit classified information will be promptly reported to the Federal Bureau of Investigation.
False statements
Paragraph 6 says Section 1001 of Title 18, United States Code, provides criminal penalties for knowingly and willfully falsifying or concealing material fact in a statement to any department or agency.
Edition
The footer prints OPTIONAL FORM 109 and 994. GSA's page gives a current revision date of 09/1994.
Related forms
Who fills out OF 109?
The form names two people: the separating employee and an interviewing officer.
Official sources and the blank
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Questions about Form OF109
Who issues OF 109?
The form is marked STATE-USIA at the top and bottom, and its text refers to the Department of State and the United States Information Agency. GSA hosts a copy in its forms library.
When is OF 109 signed?
The employee makes the statement in connection with separation from employment. The form says separation includes suspension for any period in excess of 30 days, retirement from active duty, transfer to another agency, resignation and furlough to enter military service.
Who signs OF 109?
The employee signs in the presence of the interviewing officer, and the interviewing officer signs too, with a typed name and post, department or agency.
What does OF 109 say about documents?
The employee states that all classified or administratively controlled documents and material, and all unclassified documents relating to official business, were surrendered to responsible officials.
What does OF 109 say about disclosures to Congress?
The form says its restrictions do not supersede, conflict with or otherwise alter rights created by Executive Order 12356, Section 7211 of Title 5, United States Code (governing disclosures to Congress), the Military Whistleblower Protection Act and the other laws it lists.
What is the security debriefing line?
Paragraph 5 asks the employee to strike out have or have not to show whether a security debriefing was received.