Attachment 8 - Contractor Processing Request Form.pdf

Department of the Treasury/Departmental Offices Contractor Suitability Processing Request Form

(Use for both classified and unclassified contracts) Name of Contracting Officer’s Representative (COR) Office Phone

COR’s Title COR’s Office Today’s Date (mm/dd/yyyy)

Expected Start Date (mm/dd/yyyy)

Expected End Date (mm/dd/yyyy) Full Time Sponsoring Treasury Office/Building

Location: (E.g. OFS, 1801 L St.)

Part Time

Name of Contract Company Contract Details Award Date (mm/dd/yyyy)

# of Option Years Number

Task Order #:

Contractor’s Full Name Social Security Number Last First Middle

Date of Birth (mm/dd/yyyy)

Place of Birth* (City, State, Country) *If born outside of the U.S., provide legal status documentation. Citizenship U.S. OTHER

If OTHER, country:

Contractor’s Home Address (physical location only, no P.O. Boxes) Street City State Zip

Home Phone Day-Time Phone E-mail Address

Treasury Position Title Physical Treasury Work Location (E.g. Main Treasury, Room 2000)

PIV Card Required: YES NO Is this a classified contract? NO If no, complete left side. YES If yes, complete right side.

Select Position Sensitivity: (Mark only one risk level) Select Clearance Level:

Non-IT Position Risk Level: Low Moderate High

Secret Top Secret IT Position Risk Level: Moderate High

Refer to Contract Performance Work Statement and/or Treasury Security Manual TD P 15-71, Chapter 1, Position Sensitivity and Risk Designation.

Privacy Act Notice: The information requested is protected by the Privacy Act, 5 U.S.C. 552a which requires that Federal agencies inform individuals, at the time information is solicited from them, whether the disclosure is mandatory or voluntary, by what authority such information is solicited, and what uses will be made of the information. You are hereby advised that the authority for soliciting your Social Security Number (SSN) is Executive Order 9397 which authorizes agencies to solicit SSNs for use as identifiers for administrative purposes. This form will be used as a means to conduct the required background investigation and suitability determination. Providing the information requested, including the SSN, is voluntary; however, failure to complete this form could result in your being found unsuitable for contract performance.

Email completed form and/or questions to contractorsuitability@treasury.gov by clicking the button below.

SUBJECT: CONTRACTOR SUITABILITY - (ENTER CONTRACTOR NAME)

The Personnel Security Branch can be reached by calling (202) 622-1112.

TD Form 15-03.10 (Revised 2/8/2016, previous editions obsolete)

Attachment 8 mailto:contractorsuitability@treasury.gov