NOTIFICATION OF CANCELLATION(S) OF
                 CLASSIFICATION/DECLASSIFICATION AUTHORITY

1.  NAME OF INDIVIDUAL FOR WHOM AUTHORITY IS BEING CANCELLED:

    ________________________________________________________________
        (First)        (Middle Initial)            (Last)

2.  TITLE AND ORGANIZATION OF INDIVIDUAL WHOSE AUTHORITY IS BEING
    CANCELLED:

    ________________________________________________________________

3.  LEVEL AND TYPE OF AUTHORITY BEING CANCELLED:

    _____  Top Secret Original         _____ Top Secret Derivative

    _____  Secret Original             _____ Secret Derivative

    _____ Derivative Declassification

4.  EFFECTIVE DATE OF AUTHORITY CANCELLATION: ______________________

5.  REASON FOR CANCELLING: _________________________________________

6.  NEW TITLE AND ORGANIZATION OF INDIVIDUAL IF STILL IN THE DOE:
    ________________________________________________________________


_______________________________________           __________________
Signature of Requesting Official -                       Date
MUST BE OFFICE DIRECTOR OR ABOVE

_______________________________________           __________________
Name - Typed                                             Title