27 - SF328-18 Foreign Ownership Financial Representation.pdf

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DRAFT

SAMPLE

PREVIOUS EDITION IS OBSOLETE.

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STANDARD FORM 328 (REV. 11/2018)

DRAFT

INSTRUCTIONS

NEEDS DD67

PREVIOUS EDITION IS OBSOLETE.

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DD FORM XXXX, 20YYMMDD DRAFT

CERTIFICATE PERTAINING TO FOREIGN INTERESTS

(Type or print all answers) OMB No. 0704-0579 OMB approval expires October 21, 2021

RETURN THE CURRENT FORM AS DESCRIBED BELOW.

Return the form to your respective Cognizant Security Agency/Office granting the entity’s eligibility determination (e.g., facility security clearance) as referenced in 32 CFR Part 2004 under the National Industrial Security Program (NISP); to the Department of Homeland Security for the Classified Critical Infrastructure Protection Program (CCIPP); or, to the Government Contracting Activity for the DoD Enhanced Security Program (DESP). The public reporting burden for this collection of information, 0704-0579, is estimated to average 70 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding the burden estimate or burden reduction suggestions to the Department of Defense, Washington Headquarters Services, at whs.mc-alex.esd.mbx.dd-dod-information-collections@mail.mil. Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number.

PENALTY NOTICE

Failure to answer all questions or any misrepresentation (by omission or concealment, or by misleading, false, or partial answers) may serve as a basis for denial of clearance for access to classified information. In addition, Title 18, United States Code section 1001, makes it a criminal offense to knowingly make false statements or representations to any Department or Agency of the United States, as to any matter within the jurisdiction of any Department or Agency of the United States. This includes any statement made here in which is knowingly incorrect, incomplete, or misleading in any important particular.

PROVISIONS

1. The collection of this information is authorized by the Secretary of Defense, as Executive Agent for the NISP, pursuant to Executive Order 12829, further amended by Section 6, of Executive Order 13691 to include the CCIPP. While you are not required to respond, your entity’s eligibility determination cannot be adjudicated if you do not complete the form. The retention of an entity eligibility determination is contingent upon your compliance with the requirements of DoD 5220.22-M or equivalent for submission of an accurate initial or revised form, as appropriate. This collection of information is also authorized by the Secretary of Defense for use in connection with the DESP for the Department of Defense Innovation Initiative in accordance with subsection 951(c) of Public Law 114-328 (10 USC 1564 note). While you are not required to respond, your eligibility to participate in the DESP cannot be determined if you do not complete this form accurately. Participation in the DESP is contingent, among other things, upon your compliance with the requirements of the DESP for submission of an initial or revised form, as appropriate.

2. When this report is submitted in confidence and is so marked, applicable exemptions to the Freedom of Information Act (FOIA) will be invoked to withhold it from the public disclosure if it is responsive to a FOIA request.

3. Complete all questions on this form. Mark “Yes” or “No” for each question. If your answer is “Yes” furnish complete supporting documentation, to include, but not limited to, company or entity charter documents, board meeting minutes, stock or securities information, descriptions of organizational structures; contracts, sales, leases, and/or loan agreements; and revenue documents, annual reports and income statements, etc.

1. (Answer 1a. or 1b.)

a. (For entities which issue stock): Do any foreign person(s), directly or indirectly, own or have beneficial ownership of 5 percent or more of the outstanding shares of any class of your organization's equity securities?

b. (For entities which do not issue stock): Has any foreign person directly or indirectly subscribed 5 percent or more of your organization's total capital commitment?

YES

NO

2. Does your organization directly, or indirectly through your subsidiaries and/or affiliates, own 10 percent or more of any foreign interest?

3. Do any non-U.S. citizens serve as members of your organization's board of directors (or similar governing body), officers, executive personnel, general partners, regents, trustees or senior management officials?

4. Does any foreign person(s) have the power, direct or indirect, to control the election, appointment, or tenure of members of your organization's board of directors (or similar governing body) or other management positions of your organization, or have the power to control or cause the direction of other decisions or activities of your organization?

5. Does your organization have any contracts, agreements, understandings, or arrangements with a foreign person(s)?

6. Does your organization, whether as borrower, surety, guarantor or otherwise have any indebtedness, liabilities or obligations to a foreign person(s)?

7. During your last fiscal year, did your organization derive:

a. 5 percent or more of its total revenues or net income from any single foreign person?

b. Is the aggregate 30 percent or more of its revenues or net income from foreign persons?

8. Is 10 percent or more of any class of your organization's voting securities held in "nominee" shares, in "street names" or in some other method which does not identify the beneficial owner?

9. Do any of the members of your organization's board of directors (or similar governing body), officers, executive personnel, general partners, regents, trustees or senior management officials hold any positions with, or serve as consultants for, any foreign person(s)?

10. Is there any other factor(s) that indicates or demonstrates a capability on the part of foreign persons to control or influence the operations or management of your organization?

CERTIFICATION

I CERTIFY that the entries made by me above are true, complete, and correct to the best of my knowledge and belief and are made in good faith.

Witnesses:

By NOTE: The witness must be a person who personally observed the Contractor Representative sign this form. The witness cannot be the same person who accepts this form as the Government representative. The name of the witness should be typed or printed under the witness' signature and date.

AUTHORITY: DoD 5200.2-R, Department of Defense Personnel Security Program Regulation; E.O. 12829, National Industrial Security Program; the DISS Account Management Policy; and E.O. 9397, as amended.

PRINCIPAL PURPOSE(S): To request the establishment of user roles and access and validate the trustworthiness of individuals seeking access to DCII, SWFT, or DISS (CATS or JVS) ROUTINE USE(S): The blanket routine uses found at http://dpclo.defense.gov/privacy/SORNs/blanket_routine_uses.html may apply.

DISCLOSURE: Voluntary. However, failure to provide the requested information may impede, delay, or prevent further processing of your request. The Social Security Number is used to verify the trustworthiness status in DISS.

and has the authority to make the entries above on behalf of the business entity identified above.

9.0.0.2.20120627.2.874785 Certificate Pertaining to Foreign Interests