Attachment 5 DD254 Security Clearance form.pdf

(Updated 20250815) CLASSIFICATION (When filled in): CUI

CLASSIFICATION (When filled in): CUI PREVIOUS EDITION IS OBSOLETE. Page 1 of 4DD FORM 254, APR 2018

DEPARTMENT OF DEFENSE

CONTRACT SECURITY CLASSIFICATION SPECIFICATION

(The requirements of the National Industrial Security Program (NISP) apply to all security aspects of this effort involving classified information.)

OMB No. 0704-0567 OMB approval expires:

August 31, 2028

The public reporting burden for this collection of information, 0704-0567, is estimated to average 36 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 this burden estimate or any other aspect of this collection of information, including suggestions for reducing the burden, 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.

RETURN COMPLETED FORM AS DIRECTED IN THE INSTRUCTIONS.

1. CLEARANCE AND SAFEGUARDING

a. LEVEL OF FACILITY SECURITY CLEARANCE (FCL) REQUIRED (See Instructions)

b. LEVEL OF SAFEGUARDING FOR CLASSIFIED INFORMATION/

MATERIAL REQUIRED AT CONTRACTOR FACILITY

2. THIS SPECIFICATION IS FOR: (X and complete as applicable.)

a. PRIME CONTRACT NUMBER (See instructions.)

b. SUBCONTRACT NUMBER

c. SOLICITATION OR OTHER NUMBER

M00264-26-R-0005

DUE DATE (YYYYMMDD)

3. THIS SPECIFICATION IS: (X and complete as applicable.)

a. ORIGINAL (Complete date in all cases.)

DATE (YYYYMMDD)

b. REVISED (Supersedes all previous specifications.)

REVISION NO. DATE (YYYYMMDD)

c. FINAL (Complete Item 5 in all cases.) DATE (YYYYMMDD)

4. IS THIS A FOLLOW-ON CONTRACT? No Yes If yes, complete the following:

Classified material received or generated under (Preceding Contract Number) is transferred to this follow-on contract.M00264-22-C-0002

5. IS THIS A FINAL DD FORM 254? No Yes If yes, complete the following:

In response to the contractor's request dated , retention of the classified material is authorized for the period of:

6. CONTRACTOR (Include Commercial and Government Entity (CAGE) Code)

a. NAME, ADDRESS, AND ZIP CODE b. CAGE CODE c. COGNIZANT SECURITY OFFICE(S) (CSO) (Name, Address, ZIP Code, Telephone required; Email Address optional)

Defense Security Service (IOFCC2) 13873 Park Center Road, Suite 125 Herndon, VA 20171

(571) 373-5250

7. SUBCONTRACTOR(S) (Click button if you choose to add or list the subcontractors -- but will still require a separate DD Form 254 issued by a prime contractor to each subcontractor)

a. NAME, ADDRESS, AND ZIP CODE Forward a copy of ALL SIGNED Sub-DD-254s to the Security Officer designated in Block 17.

b. CAGE CODE c. COGNIZANT SECURITY OFFICE(S) (CSO) (Name, Address, ZIP Code, Telephone required; Email Address optional)

8. ACTUAL PERFORMANCE (Click button to add more locations.)

a. LOCATION(S) (For actual performance, see instructions.) b. CAGE CODE (If applicable, see Instructions.)

c. COGNIZANT SECURITY OFFICE(S) (CSO) (Name, Address, ZIP Code, Telephone required; Email Address optional)

Defense Security Service (IOFCC2) 13873 Park Center Road, Suite 125 Herndon, VA 20171

(571) 373-5250

a. LOCATION(S) (For actual performance, see instructions.) b. CAGE CODE (If applicable, see Instructions.)

c. COGNIZANT SECURITY OFFICE(S) (CSO) (Name, Address, ZIP Code, Telephone required; Email Address optional)

PREVIOUS EDITION IS OBSOLETE. Page 2 of 4DD FORM 254, APR 2018

a. LOCATION(S) (For actual performance, see instructions.) b. CAGE CODE (If applicable, see Instructions.)

c. COGNIZANT SECURITY OFFICE(S) (CSO) (Name, Address, ZIP Code, Telephone required; Email Address optional)

a. LOCATION(S) (For actual performance, see instructions.) b. CAGE CODE (If applicable, see Instructions.)

c. COGNIZANT SECURITY OFFICE(S) (CSO) (Name, Address, ZIP Code, Telephone required; Email Address optional)

9. GENERAL UNCLASSIFIED DESCRIPTION OF THIS PROCUREMENT

Requirement for professional, management, and technical support services to assist TECOM in the support of Range and Training Area management. Classified work to be performed at TECOM Government facilities. Some non-classified work to be at the contractor facilities.

10. CONTRACTOR WILL REQUIRE ACCESS TO: (X all that apply. Provide details in Blocks 13 or 14 as set forth in the instructions.)

a. COMMUNICATIONS SECURITY (COMSEC) INFORMATION f. SPECIAL ACCESS PROGRAM (SAP) INFORMATION

b. RESTRICTED DATA

g. NORTH ATLANTIC TREATY ORGANIZATION

(NATO) INFORMATION

c. CRITICAL NUCLEAR WEAPON DESIGN INFORMATION (CNWDI) (If CNWDI applies, RESTRICTED DATA must also be marked.)

h. FOREIGN GOVERNMENT INFORMATION

d. FORMERLY RESTRICTED DATA

i. ALTERNATIVE COMPENSATORY CONTROL MEASURES

(ACCM) INFORMATION

e. NATIONAL INTELLIGENCE INFORMATION:

(1) Sensitive Compartmented Information (SCI)

(2) Non-SCI

j. CONTROLLED UNCLASSIFIED INFORMATION (CUI) (See instructions.)

k. OTHER (Specify) (See instructions.)

11. IN PERFORMING THIS CONTRACT, THE CONTRACTOR WILL: (X all that apply. See instructions. Provide details in Blocks 13 or 14 as set forth in the instructions.)

a. HAVE ACCESS TO CLASSIFIED INFORMATION ONLY AT

ANOTHER CONTRACTOR'S FACILITY OR A GOVERNMENT

ACTIVITY

(Applicable only if there is no access or storage required at contractor facility.

See instructions.)

b. RECEIVE AND STORE CLASSIFIED DOCUMENTS ONLY

c. RECEIVE, STORE, AND GENERATE CLASSIFIED

INFORMATION OR MATERIAL

d. FABRICATE, MODIFY, OR STORE CLASSIFIED HARDWARE

e. PERFORM SERVICES ONLY

f. HAVE ACCESS TO U.S. CLASSIFIED INFORMATION OUTSIDE

THE U.S.,PUERTO RICO, U.S. POSSESSIONS AND TRUST

TERRITORIES

g. BE AUTHORIZED TO USE THE SERVICES OF DEFENSE

TECHNICAL INFORMATION CENTER (DTIC) OR OTHER

SECONDARY DISTRIBUTION CENTER

h. REQUIRE A COMSEC ACCOUNT

i. HAVE A TEMPEST REQUIREMENT

j. HAVE OPERATIONS SECURITY (OPSEC) REQUIREMENTS

k. BE AUTHORIZED TO USE DEFENSE COURIER SERVICE

l. RECEIVE, STORE, OR GENERATE CONTROLLED UNCLASSIFIED

INFORMATION (CUI).

(DoD Components: refer to DoDI 5200.48, only for specific CUI protection requirements. Non-DoD Components: see instructions.)

m. OTHER (Specify) (See instructions.)

12. PUBLIC RELEASE

Any information (classified or unclassified) pertaining to this contract shall not be released for public dissemination except as provided by the National Industrial Security Program Operating Manual (NISPOM) or unless it has been approved for public release by appropriate U.S. Government authority.

Proposed public releases shall be submitted for review and approval prior to release to the appropriate government approval authority identified here with at least office and phone contact information and if available, an e-mail address. (See instructions)

PREVIOUS EDITION IS OBSOLETE. Page 3 of 4DD FORM 254, APR 2018

DIRECT THROUGH (Specify below)

PUBLIC AFFAIRS OFFICER

3300 Russell Road

Public Release Authority:

All requests must be approved by AC/S G-2, OPSEC, & Office of Public Affairs & Communication (OPAC): MCSCPAO@usmc.mil

13. SECURITY GUIDANCE

The security classification guidance for classified information needed for this effort is identified below. If any difficulty is encountered in applying this guidance or if any other contributing factor indicates a need for changes in this guidance, the contractor is authorized and encouraged to provide recommended changes; to challenge the guidance or the classification assigned to any information or material furnished or generated under this contract;

and to submit any questions for interpretation of this guidance to the official identified below. Pending final decision, the information involved shall be handled and protected at the highest level of classification assigned or recommended.

(Fill in as appropriate for the classified effort. Attach, or forward under separate correspondence, any documents/guides/extracts referenced herein. The field will expand as text is added. When removing any expanded text area, use delete key or backspace key, then click out of the text field for it to shrink after the text has been deleted. Also allows for up to 6 internal reviewers to digitally sign. See instructions for additional guidance or use of the fillable

PDF.)

This effort has been reviewed and found not to include any of the following thresholds which would dictate higher level review:

Is any portion of the SOW, PWS or supporting documents classified?

Does the SOW, PWS or other requirements necessitate the use of Sensitive Compartmented Information (SCI) caveats/controls?

Does the requirement support a sensitive activity, sensitive operation or the use of tradecraft?

Is there any portion of the work to be performed that cannot be published openly? (This does not include CUI markings.)

The Security Classification Guide (SCG) utilized for this effort is: *********************************

10j. The contractor shall comply with the requirements of the SECNAVINST 5510.36B and DoDI 5200.48 for guidance when access to CUI is required in performance of this contract.

11j. See [14.] Additional Security Requirements for OPSEC Requirements while performing aboard NAVY/USMC sites.

11l. Receive, Store, or Generate Controlled Unclassified Information (CUI). In addition to classified information, certain types of unclassified information also require distribution controls and protective measures for a variety of reasons. Refer to DoDI 5200.48 for guidance with identification and protection of CUI.

Per MCO 5510.18B (1) The DD-254 shall be signed by the COSR. At no time shall DD-254s be accepted if found to be signed by the FSO or other contractor unless that DD-254 is for a subcontract. The DD-254 is invalid unless signed by the proper official.

NOTE: The appointed Contracting Officer Security Representative (COSR) listed in Section 17 is the authorized official for

MARCORSYSCOM.

At the end of period of performance for this effort, the COSR designated in Section 17 must be notified by the Prime Contractor in order to close out this DD-254. If applicable, coordinate the return of classified material from contractor's facility.

List of Attachments (All Files Must be attached Prior to Signing, i.e., for any digital signature on the form)

Signature authority for this effort is: NAME & TITLE OF REVIEWING OFFICIAL

Jeff Grunigen, TECOM SctyMgr

SIGNATURE

14. ADDITIONAL SECURITY REQUIREMENTS

Requirements, in addition to NISPOM requirements for classified information, are established for this contract.

No Yes If Yes, identify the pertinent contractual clauses in the contract document itself, or provide an appropriate statement which identifies the additional requirements. Provide a copy of the requirements to the CSO. The field will expand as text is added or you can also use item 13. When removing any expanded text area, use delete key or backspace key, then click out of the text field for it to shrink after the text has been deleted.

(See instructions for additional guidance or use of the fillable PDF.)

11j. OPSEC Requirements. While performing aboard NAVY/USMC sites, the contractor shall comply with the provisions of DoD Directive 5205.02E, "DoD Operations Security (OPSEC) Program," SECNAV 3070.2, CMDO 3070.1B, MCO 3070.2A, and the MARCORSYSCOMO P5510.2B Security Manual, at all other sites the contractor shall comply with the local command and/or program OPSEC plan.

GRUNIGEN.JEFFR

EY.A.1034144326

Digitally signed by

GRUNIGEN.JEFFREY.A.1034144

Date: 2026.07.21 12:42:33 -04'00'

PREVIOUS EDITION IS OBSOLETE. Page 4 of 4DD FORM 254, APR 2018

15. INSPECTIONS

Elements of this contract are outside the inspection responsibility of the CSO.

No Yes If Yes, explain and identify specific areas and government activity responsible for inspections. The field will expand as text is added or you can also use item

13. When removing any expanded text area, use delete key or backspace key, then click out of the text field for it to shrink after the text has been deleted.

(See instructions for additional guidance or use of the fillable PDF.)

Inspection responsibility is with the respective security managers at the government facilities where classified work is performed.

16. GOVERNMENT CONTRACTING ACTIVITY (GCA) AND POINT OF CONTACT (POC)

a. GCA NAME

Range and Training Area Management

b. ACTIVITY ADDRESS CODE (AAC) OF THE CONTRACTING OFFICE (See Instructions)

c. ADDRESS (Include ZIP Code) 2007 Elliot Road Quantico, VA 22134

d. POC NAME

Carlos Hathcock

e. POC TELEPHONE (Include Area Code)

+1 (703) 784-2841

f. EMAIL ADDRESS (See Instructions) carlos.n.hathcock@usmc.mil

17. CERTIFICATION AND SIGNATURES

Security requirements stated herein are complete and adequate for safeguarding the classified information to be released or generated under this classified effort. All questions shall be referred to the official named below. Upon digitally signing Item 17h, no changes can be made as the form will be locked.

a. TYPED NAME OF CERTIFYING OFFICIAL (Last, First, Middle Initial) (See Instructions)

b. TITLE

Contracting Security Official

c. ADDRESS (Include ZIP Code)

d. AAC OF THE CONTRACTING OFFICE (See Instructions)

M67854

e. CAGE CODE OF THE PRIME CONTRACTOR (See Instructions.)

f. TELEPHONE (Include Area Code)

g. EMAIL ADDRESS (See Instructions)

h. SIGNATURE

i. DATE SIGNED (See Instructions)

18. REQUIRED DISTRIBUTION BY THE CERTIFYING OFFICIAL

a. CONTRACTOR

b. SUBCONTRACTOR

c. COGNIZANT SECURITY OFFICE FOR PRIME AND

SUBCONTRACTOR

d. U.S. ACTIVITY RESPONSIBLE FOR OVERSEAS SECURITY

ADMINISTRATION

e. ADMINISTRATIVE CONTRACTING OFFICER

f. OTHER AS NECESSARY (If more room is needed, continue in Item 13 or on additional page if necessary.)