Attachment 1 Form FTC-SEM-34 FLETC Statement.pdf

This is a blank statement form template used by the Federal Law Enforcement Training Center (FLETC) for health services contract documentation. The form, designated FTC-SEM-34 (06/06), is classified as "For Official Use Only" and serves as Part 9, Attachment 1 of a Health Services Contract.

The form provides space for recording a date, time, and subject matter of a statement, with signature lines for both the individual providing the statement (print name, agency, class number, and class coordinator information) and the receiving officer. The form includes a certification statement requiring the signatory to affirm that all information provided is true and accurate, with acknowledgment that false information violates 18 USC 1001. The document also contains privacy act language referencing 5 USC 552a(3), authority citations including 5 USC 301 and 5 USC 4001 et seq., and notes that disclosure is voluntary. This is a blank template with multiple blank lines for narrative content rather than a completed document addressing specific contract requirements, products, or services.