Form J-119 - Data Sharing Request/agreement Page 6
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8J-119 DSA (7-17) - Page 6 of 8
Agreement No.
SECTION V. APPROVAL
(Completed by the requesting entity and the data managing program)
I attest to the correctness of the information provided in Section I and agree to the stipulations and costs if any listed in
Section III. I agree to comply with all provisions of the DES Data Security Policy. If any violations of the DES Data Security
Policy occur, this Agreement may be terminated. I further understand that DES will periodically review the terms of the
Agreement to ensure it conforms with DES Policies and Procedures. In the event changes in either federal or state law or
regulations occur that conflict with the terms of the Agreement or render the terms of the Agreement void, impracticable,
or otherwise impossible, this Agreement will terminate immediately. A new Agreement or an amendment to the existing
Agreement will be initiated to provide for any changes that cannot be accommodated within the provisions of the existing
Agreement. The Requesting Entity shall hold harmless and indemnify the State of Arizona and its Department of Economic
Security for any liability resulting from acts or omissions attributable to the Requesting Entity.
IN WITNESS HERETO, the PARTIES have executed this Agreement by signature of their duly authorized officials:
FOR THE REQUESTING ENTITY: (Completed by requesting Entity)
Entity Name:
Print Signatory Name:
Title:
Signature:
Date:
FOR THE DEPARTMENT OF ECONOMIC SECURITY: (Completed by Data Managing Program)
Entity Name:
Print Signatory Name:
Title:
Signature:
Date:
SECTION VI. APPROVAL
(Completed by Information Risk Management)
This signed Agreement meets all requirements necessary to permit the controlled sharing of the DES data while simultaneously providing
for the protection of the data. I certify that:
THIS AGREEMENT CONFORMS TO DES Information Security Policy [DES 1-38-0006].
THIS AGREEMENT DOES NOT CONFORM to the DES Information Security Policy. Implementation of this agreement
cannot proceed until the following action is taken:
DES Chief Information Security Officer
(Signature)
(Title)
(Date)
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