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Exhibit 6–4: Sample Affidavit of Nondisclosure by Researchers

I, [name of individual], do solemnly [swear or affirm] that when given access to the [title of data to be provided] provided by [name of the agency or school], I shall not:

1. use or reveal any personally identifiable information furnished, acquired, retrieved, or assembled by me or others, under the provisions of [citation of applicable laws] for any purpose other than statistical purposes specified in the [name of agreement];
2. make any release or publication whereby an individual could be identified or the data furnished by or related to any particular person can be identified; or
3. permit anyone other than the individuals authorized by [name of the agency or school] to examine the individual reports.

Signature: ______________________________________

Name: ______________________________________

Title: ______________________________________

Organization: ______________________________________

Date: ______________________________________

The penalty for unlawful release is [maximum penalties as specified by the applicable laws and provide citations].

Notary Public and Seal: ______________________________________

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