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

This is a federal form (FTC-SEM-34) serving as a statement template for the Federal Law Enforcement Training Center's Health Services Contract. The document is marked "FOR OFFICIAL USE ONLY" and is classified as Part 9, Attachment 1 of a health services contracting document.

The form functions as a blank statement template with designated fields for DATE, TIME, and SUBJECT matter, followed by extensive blank lined space for narrative content. At the bottom, the form requires identification information including Print Name, Agency, Class Number, and Class Coordinator, along with signature lines for both the submitting party and a Receiving Officer. The form includes a certification statement declaring that all information provided is true and acknowledges that false information violates 18 USC 1001. A Privacy Act Statement references authority under 5 USC 301, 5 USC 4001 et seq., Executive Order No. 11348, and Department of Homeland Security Delegation Number 7050, noting that disclosure is voluntary. The document is paginated with space to indicate page numbers. This is a template document without specific contract requirements, products, services, pricing, or response dates specified.