4_CUI Building Information Request Form.pdf
PDF 91 KB Posted
- Attached to
- NASA Ames Engineering and Mission Operations Facility Design-Build Services Solicitation
- Solicitation number
- 47PB5426R0014
- Issued by
- Not on record
About this file
This document is a template form for requesting access to Controlled Unclassified Information (CUI) building information in federal contracting solicitations, along with a corresponding disposal statement.
The Request for CUI Building Information form requires offerors, bidders, or contractors to complete identification information including company name, individual name and title, signature, and date. Requestors must attach a copy of their business license or formation document and provide their SAM Unique Entity Identifier (UEI) number, which the government representative verifies through https://www.sam.gov. The form also requires the Employer ID Number or Federal Tax ID Number. By signing the form, the requester acknowledges understanding the requirement to maintain controls to safeguard the CUI building information and commits to returning or destroying the information as required. The requester further agrees to abide by the agreement terms and only disseminate CUI building information to other authorized users under specified conditions. The Contracting Officer, identified as Jamie Potter, must verify the offeror/bidder/contractor information and UEI number before approving release of the CUI building information, with signature and date required on the form.
The Disposal Statement for CUI Building Information is a certification form completed by the same parties upon conclusion of their involvement with the solicitation or contract. The signatory certifies that all CUI building information not previously returned to the government has been destroyed through burning or shredding paper copies, physically destroying computer diskettes, or permanently deleting electronic files from computers. The form also requires certification that no unauthorized physical or electronic copies were made or are being retained. Required fields include company name, individual name, signature, title, and date.
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Text version
REQUEST FOR CONTROLLED UNCLASSIFIED INFORMATION (CUI) BUILDING
INFORMATION
Solicitation/Contract Number ________________________________________
The requester shall complete the information below and return the entire Request for CUI Building Information document to the Contracting Officer or Contract Specialist. By signature below, the requestor of CUI building information acknowledges the requirement to maintain controls, as stated herein, to safeguard the information, and shall return or destroy the CUI building information as required by this Agreement. The undersigned acknowledges that the requester shall abide by this Agreement and shall only disseminate CUI building information to other authorized users under the conditions set forth herein.
Company Name: _____________________________________________________
Name of Individual and Title: ____________________________________________
Signature: ___________________________________________________
Date: _______________________________________________________
(The Offeror shall attach copy of business license or formation document.)
SAM UEI Number: _________________________________________
UEI Number Verified by Government Representative at:
https://www.sam.gov/portal/public/SAM/#1 Yes: ___ No: ___
Employer ID Number/Federal Tax ID Number _______________________________
Offeror/bidder/contractor information and UEI number has been verified and release of CUI building information is approved by:
Date
Jamie Potter Contracting Officer https://www.sam.gov/portal/public/SAM/#1
DISPOSAL STATEMENT FOR CUI BUILDING INFORMATION
Solicitation/Contract Number ________________________________________
I hereby certify that all CUI building information relative to the referenced solicitation/contract not previously returned to the Government has been destroyed or disposed of by burning or shredding paper copies, physically destroying computer diskettes or permanently deleting/removing/erasing electronic files from computers.
I also certify that no unauthorized physical or electronic copies of such CUI building information were made or are being retained.
Company Name: ______________________________________________
Name of Individual: ____________________________________________
Signature: ___________________________________________________
Title: _______________________________________________________
Date: _________________
File details come from the government source that posted it. Updated .