96-S Exhibit A - SSA-222 - Contractor Personnel Security Certification.pdf

Security Awareness Contractor / Affiliate Personnel Security Certification

Purpose: This form is to be signed by contractor or affiliate personnel to certify that they have received and understand SSA's Security Awareness Training requirements detailed below.

Background: I understand that SSA maintains a variety of sensitive information about the agency's operations and programs (hereinafter "SSA information"), which may be information pertaining to program (e.g., information about SSA's clients) or non-program (e.g., administrative and personnel records) matters. I understand that SSA may authorize me to have access to SSA information and that my access to and use of SSA information must be in accordance with the provisions of the contract under which I am performing work for SSA and/or the terms of any other written agreement that authorizes me to access SSA information.

I have read, understand, and agree that:

1. I will not inspect, access, or attempt to access any SSA information that SSA has not expressly authorized me to access.

2. I will not release or disclose any SSA information to any unauthorized person, agency, or entity. I understand that unauthorized disclosure of SSA information may lead to civil penalties and/or criminal prosecution under Federal law (i.e., The Privacy Act of 1974, 5 U.S.C. 552a; SSA's regulations at 20 C.F R. Part 401; The Social Security Act, 42 U.S.C. 1306(a); and 5 U.S.C. Section 552(i)). I further understand that additional privacy and disclosure protections may apply to certain types of SSA information, including Federal Tax Information (i.e., earnings information), which may be subject to additional penalties under sections 6103, 7213, 7213A, and 7431 of the Internal Revenue Service (IRS) Code (Title 26 of the United States Code).

3. I will follow all access, retention, and/or destruction requirements in the contract and/or agreement under which I am authorized to access SSA information. I understand that such requirements may require me to cease access to, return, or destroy SSA information upon completion of my work for SSA or termination of my contract or agreement that authorized my access to SSA information.

4. I will not take SSA information off-site, unless expressly authorized to do so by contract or other written authorization from SSA. If SSA authorizes me to take SSA information off-site, I agree to safeguard all SSA information in accordance with agency policy and standards so that no unauthorized person, agency, or entity can access SSA's information.

5. I will keep confidential any third-party proprietary information that may be entrusted to me as part of the contract, including safeguarding such information from unauthorized access and not disclosing or releasing such information unless expressly authorized to do so.

6. I will follow all SSA terms, conditions, and policies in the contract under which I am performing work for SSA and/or the terms of any other written agreement that authorizes me to access SSA information, including but not limited to those governing confidential information or personally identifiable information.

7. I will follow all SSA Standards of Conduct, and Rules of Behavior for Users and Managers of SSA's Automated Information Resources.

8. I understand that the contract and/or agreement terms take precedent over this document.

9. I understand that any questions I may have concerning authorization(s) should be directed to the Contracting Officer designated in my company's contract.

Contractor Employee Name (Print/Type) Date (MM/DD/YYYY)

Contractor Employee Signature (Sign)

Contract Number Company Name (Print/Type)

Company Point Of Contact (Print/Type) Company Point of Contact Phone Number

Form SSA-222 (10-2016) Discontinue Previous Editions

Page 1 of 2Social Security Administration

Privacy Act

42 U.S.C. § 904(a); 20 C.F.R. § 401.90; 44 U.S.C. §§ 3541-3549; 41 C.F.R. Chapter 101;

5 U.S.C. § 552a(e)(9)-(10); and Executive Order 13488 allow us to collect the information on this form. We will use the information to authorize you to have access to Social Security Administration (SSA) information. The Privacy Act (5 U.S.C. & 552a(b)) permits us to disclose the information you provide on this form in accordance with approved routine uses. Providing us your information is voluntary. However, not providing the information could prevent us from authorizing you access to SSA information. Additional information regarding this form, routine uses of information, and other Social Security programs, is available on our Internet website, www.socialsecurity.gov, or at your local Social Security office.

Page 2 of 2Form SSA-222 (10-2016) www.socialsecurity.gov

Security Awareness Contractor Personnel Security Certification

SSA

SSA-222

Security Awareness Contractor / Affiliate Personnel Security Certification Social Security Administration (SSA) Security Awareness Contractor Personnel Security Certification Purpose:

This form is to be signed by contractor or affiliate personnel to certify that they have received and understand SSA's Security Awareness Training requirements detailed below.

Background:

I understand that SSA maintains a variety of sensitive information about the agency's operations and programs (hereinafter "SSA information"), which may be information pertaining to program (e.g., information about SSA's clients) or non-program (e.g., administrative and personnel records) matters. I understand that SSA may authorize me to have access to SSA information and that my access to and use of SSA information must be in accordance with the provisions of the contract under which I am performing work for SSA and/or the terms of any other written agreement that authorizes me to access SSA information.

I have read, understand, and agree that:

1. I will not inspect, access, or attempt to access any SSA information that SSA has not expressly authorized me to access.

2. I will not release or disclose any SSA information to any unauthorized person, agency, or entity. I understand that unauthorized disclosure of SSA information may lead to civil penalties and/or criminal prosecution under Federal law (i.e., The Privacy Act of 1974, 5 U.S.C. 552a; SSA's regulations at 20 C.F R. Part 401; The Social Security Act, 42 U.S.C. 1306(a); and 5 U.S.C. Section 552(i)). I further understand that additional privacy and disclosure protections may apply to certain types of SSA information, including Federal Tax Information (i.e., earnings information), which may be subject to additional penalties under sections 6103, 7213, 7213A, and 7431 of the Internal Revenue Service (IRS) Code (Title 26 of the United States Code).

3. I will follow all access, retention, and/or destruction requirements in the contract and/or agreement under which I am authorized to access SSA information. I understand that such requirements may require me to cease access to, return, or destroy SSA information upon completion of my work for SSA or termination of my contract or agreement that authorized my access to SSA information.

4. I will not take SSA information off-site, unless expressly authorized to do so by contract or other written authorization from SSA. If SSA authorizes me to take SSA information off-site, I agree to safeguard all SSA information in accordance with agency policy and standards so that no unauthorized person, agency, or entity can access SSA's information.

5. I will keep confidential any third-party proprietary information that may be entrusted to me as part of the contract, including safeguarding such information from unauthorized access and not disclosing or releasing such information unless expressly authorized to do so.

6. I will follow all SSA terms, conditions, and policies in the contract under which I am performing work for SSA and/or the terms of any other written agreement that authorizes me to access SSA information, including but not limited to those governing confidential information or personally identifiable information.

7. I will follow all SSA Standards of Conduct, and Rules of Behavior for Users and Managers of SSA's Automated Information Resources.

8. I understand that the contract and/or agreement terms take precedent over this document.

9. I understand that any questions I may have concerning authorization(s) should be directed to the Contracting Officer designated in my company's contract.

Contractor Employee Name (Print/Type) Date (MM/DD/YYYY) Contractor Employee Signature (Sign) Contract Number Company Name (Print/Type) Company Point Of Contact (Print/Type) Company Point of Contact Phone Number Form SSA-222 (10-2016) Discontinue Previous Editions Social Security Administration Privacy Act 42 U.S.C. § 904(a); 20 C.F.R. § 401.90; 44 U.S.C. §§ 3541-3549; 41 C.F.R. Chapter 101;

5 U.S.C. § 552a(e)(9)-(10); and Executive Order 13488 allow us to collect the information on this form. We will use the information to authorize you to have access to Social Security Administration (SSA) information. The Privacy Act (5 U.S.C. & 552a(b)) permits us to disclose the information you provide on this form in accordance with approved routine uses. Providing us your information is voluntary. However, not providing the information could prevent us from authorizing you access to SSA information. Additional information regarding this form, routine uses of information, and other Social Security programs, is available on our Internet website, www.socialsecurity.gov, or at your local Social Security office.

Form SSA-222 (10-2016)

disclosure protections may apply to certain types of SSA information, including Federal Tax Information (i.e., earnings information), which may be subject to additional penalties under sections 6 1 0 3, 7 2 1 3, 7 2 1 3Ay, and 7 4 3 1 of the Internal Revenue Service (IRS) Code (Title 26 of the United States Code). 3. I will follow all access, retention, and/or destruction requirements in the contract and/or agreement under which I am authorized to access SSA information. I understand that such requirements may require me to cease access to, return, or destroy SSA information upon completion of my work for SSA or termination of my contract or agreement that authorized my access to SSA information. 4. I will not take SSA information off-site, unless expressly authorized to do so by contract or other written authorization from SSA. If SSA authorizes me to take SSA information off-site, I agree to safeguard all SSA information in accordance with agency policy and standards so that no unauthorized person, agency, or entity can access SSA's information. 5. I will keep confidential any third-party proprietary information that may be entrusted to me as part of the contract, including safeguarding such information from unauthorized access and not disclosing or releasing such information unless expressly authorized to do so.

6. I will follow all SSA terms, conditions, and policies in the contract under which I am performing work for SSA and/or the terms of any other written agreement that authorizes me to access S S Ay information, including but not limited to those governing confidential information or personally identifiable information. 7. I will follow all S S Ay Standards of Conduct, and Rules of Behavior for Users and Managers of S S Ay's Automated Information Resources. 8. I understand that the contract and/or agreement terms take precedent over this document. 9. I understand that any questions I may have concerning authorization(s) should be directed to the Contracting Officer designated in my company's contract.