TAB_10_SBU_Information_Request_Form_-_IRS_Project_0001_0002.pdf

Revised 6/24/2015

REQUEST FOR SENSITIVE BUT UNCLASSIFIED (SBU) BUILDING INFORMATION

Solicitation/Contract Number ________________________________________

The requester shall complete the information below and return the entire Request for Sensitive but Unclassified (SBU) Building Information document to the Contracting Officer or Contract Specialist. By signature below, the requestor of SBU building information acknowledges the requirement to maintain controls, as stated herein, to safeguard the information, and shall return or destroy the SBU building information as required by this Agreement. The undersigned acknowledges that the requester shall abide by this Agreement and shall only disseminate SBU 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.)

Unique Entity Identifier (UEI) Number: _______________________________

UEI Number Verified by Government Representative at:

https://beta.sam.gov/ Yes: ___ No: ___

Employer ID Number/Federal Tax ID Number _______________________________

Offeror/bidder/contractor information and UEI number has been verified and release of SBU building information is approved by:

Joan Amend Date Contracting Officer https://beta.sam.gov/

Revised 6/24/2015

DISPOSAL STATEMENT FOR SENSITIVE BUT UNCLASSIFIED BUILDING INFORMATION

Solicitation/Contract Number ________________________________________

I hereby certify that all Sensitive but Unclassified (SBU) 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 the no unauthorized physical or electronic copies of such SBU building information were made or are being retained.

Company Name: ______________________________________________

Name of Individual: ____________________________________________

Signature: ___________________________________________________

Title: _______________________________________________________

Date: _________________