04_CUI Building Information Request Form.pdf
PDF 91 KB Posted
- Solicitation number
- 47PB5427R0003
- Issued by
- Not on record
About this file
This document is a template form for requesting and controlling Controlled Unclassified Information (CUI) related to federal building contract opportunities. The form consists of two primary sections: a Request for CUI Building Information and a Disposal Statement for CUI Building Information.
The Request section requires offerors, bidders, or contractors to complete identification information including company name, individual name and title, SAM UEI number, and Employer ID/Federal Tax ID number. Requesters must acknowledge their responsibility to maintain controls to safeguard the CUI building information and agree to return or destroy the information as required. A copy of the business license or formation document must be attached. The government representative must verify the UEI number through SAM.gov and confirm approval for CUI building information release. Jamie Potter is identified as the Contracting Officer responsible for verification and approval. The Disposal Statement section, completed upon completion of contract activities, requires certification that all CUI building information has been destroyed through burning, shredding paper copies, physically destroying computer diskettes, or permanently deleting electronic files. The signatory must also certify that no unauthorized copies were made or retained. Both sections require the solicitation/contract number, company name, individual name, signature, title, and date to be documented.
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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 .