Attch 3 - Bidders DD-254.pdf

CLASSIFICATION (When filled in):

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DD FORM 254, APR 2018 PREVIOUS EDITION IS OBSOLETE. Page 1 of 3 AEM LiveCycle Designer

DD 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:

June 30, 2025

The public reporting burden for this collection of information, 0704-0567, 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 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 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.

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)

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 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)

9. GENERAL UNCLASSIFIED DESCRIPTION OF THIS PROCUREMENT

Unclassified

Unclassified

Industrial Security Management System

19-AQMM-25-Q-0107

Top Secret None

c. SOLICITATION NUMBER

19-AQMM-25-Q-0107

✔ 20250204

X

X

Department of State locations

19AQMM

To perform preventative maintenance services on the chillers at the U.S. Embassy Podgorica, Montenegro

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DD FORM 254, APR 2018

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

b. RESTRICTED DATA

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

d. FORMERLY RESTRICTED DATA

e. NATIONAL INTELLIGENCE INFORMATION:

(1) Sensitive Compartmented Information (SCI)

(2) Non-SCI

f. SPECIAL ACCESS PROGRAM (SAP) INFORMATION

g. NORTH ATLANTIC TREATY ORGANIZATION

(NATO) INFORMATION

h. FOREIGN GOVERNMENT INFORMATION

i. ALTERNATIVE COMPENSATORY CONTROL MEASURES

(ACCM) INFORMATION

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

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 DoDM 5200.01, Volume 4 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)

DIRECT THROUGH (Specify below) Public Release Authority:

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.)

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

Unclassified

Unclassified

Industrial Security Management System

19-AQMM-25-Q-0107

k.1. SENSITIVE BUT UNCLASSIFIED INFORMATION (SBU) m.1. REQUIRE CONNECTIVITY TO DEPT. STATE COMPUTER SYSTEM

Overseas access to classified information at Department of State locations only

Department of State, DS/IS/IND, SA-20, 13th Floor, Washington, DC 20520

[ DD Form 254 Section 13 Security Guidance is provided separately starting on page 4. ]

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DD FORM 254, APR 2018

NAME & TITLE OF REVIEWING OFFICIAL 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.)

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.)

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

a. GCA NAME

b. ACTIVITY ADDRESS CODE (AAC) OF THE

CONTRACTING OFFICE (See Instructions)

c. ADDRESS (Include ZIP Code) d. POC NAME

e. POC TELEPHONE (Include Area Code)

f. EMAIL ADDRESS (See Instructions)

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

c. ADDRESS (Include ZIP Code)

d. AAC OF THE CONTRACTING OFFICE (See Instructions)

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.)

Unclassified

Unclassified

Industrial Security Management System

19-AQMM-25-Q-0107

Janice Custard-Lazarchick, WCSS Section Chief, DS/IS/IND

X

X

Department of State

19AQMM

2201 "C" Street, NW Washington, DC 20520

Janice Custard-Lazarchick

(571) 345-3023

Custard-lazarchickJN@state.gov for Kim Colon

Division Chief

DS/IS/IND, SA-20, 13th Fl.

2201 C St. NW Washington, DC 20520

19AQMM

(571) 345-3032

ColonK@state.gov

13. SECURITY GUIDANCE.

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19-AQMM-25-Q-0107

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.

Contractor personnel assigned to this contract shall possess a TOP SECRET or SECRET personnel security clearance, commensurate with their level of access, issued by the Defense Counterintelligence and Security Agency (DCSA), prior to contract performance. Uncleared individuals specifically authorized by the Contracting Officer's Representative (COR) to perform on-site in DOS facilities, only on unclassified portions of the contract and/or in areas not requiring cleared access must still be processed for DOS personal identification cards (badges) in accordance with the DOS Personal Identification Card Issuance Procedures.

**NOTE: Contractor must provide at least one Final TS cleared person for access to existing Core spaces/systems.

Visit Authorization Requests (VARs) for all cleared personnel performing on the contract at DOS locations are to be sent to DS/IS/IND via email to: DS_IND_contractorVARS@state.gov. A VAR is valid for 12 months; a VAR is required to be renewed 30 days prior to the current VAR expiring. Updated VARs are required when cleared personnel have a change to access level. A VAR cancellation must be submitted when cleared personnel are no longer performing on contract or no longer require access to classified. The Facility Security Officer (FSO) shall submit VAR cancellations within 72 hours of contract departure to DS_IND_contractorVARS@state.gov. VARs must be sent using the approved VAR form found at https://www.state.gov/industrial-security/.

All DD Forms 254 for proposed subcontractors required to provide cleared personnel shall be forwarded to DS/ IS/IND via email to DS_IND_OBOTeam@state.gov. The prime contractor shall provide a current signed (by both parties) Subcontract Agreement between the entities outlining specific Statement of Work (SOW) to be performed by the subcontractor, to include all security requirements. DD Forms 254 issued by DS/IS/IND will be provided to the prime for distribution to subcontractors, prior to subcontractor access to any classified information or spaces.

Contractors are not authorized to issue their own subcontract DD Forms 254.

The contractor is responsible for security classification review of all test/strip results developed in DOS secure spaces in accordance with the SCG. Any classified information generated at post will be generated on post provided equipment in secure spaces. The equipment and space for generating classified reports will be coordinated by the Facilities Manager (FM).

The loss, compromise, or suspected compromise of any classified or SBU information regarding this contract shall be reported immediately to the COR and DS/IS/IND. No public release of information regarding this contract shall be made without the prior approval of the Contracting Officer and DS/IS/IND.

While at DOS locations, the contractor shall comply with applicable DOS regulations relative to protection of classified and/or sensitive information, including the National Industrial Security Program Operating Manual (NISPOM) (32 CFR Part 117) and 12 Foreign Affairs Manual (FAM) 500 and 600. DS/IS/IND is responsible for reviewing contractors assigned to DOS locations.

Security clearance requirements for contractors accessing DOS domestic or overseas information systems shall be in accordance with 12 FAM 600. Furthermore, citizens of specifically designated human intelligence and/or technical intelligence threat countries shall not develop, modify, or perform maintenance on software developed for use on DOS computer systems without approval by DS/CTS.

Transmittal of project information between prime and subcontractors, between designated subcontractors, and to DOS, shall be strictly in accordance with Sections D, E, and H of the contract.

DCSA approved safeguarding is not required; therefore, no discussion, generation or storage of classified information shall take place at the contractor facility. However, the Security Classification Guide for Design and Construction of Overseas Facilities, included in Section J of the RFP, shall be utilized for identification and

13. SECURITY GUIDANCE.

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handling of SBU and SBU/NOFORN at the contractor's facility and handling of classified information at DOS locations.

All processing, storage, and transmission of SBU data on static and portable electronic media shall be in accordance with Section H of the contract. DS/IS/IND is responsible for inspecting contractor activities at DOS locations.

Contractors shall immediately report any adverse information concerning any cleared contractor employees performing on DOS contracts to DCSA in accordance with the NISPOM and to DS/IS/IND in accordance with 12

FAM 576.

Contractors shall immediately report any adverse information concerning any cleared contractor employees performing on DOS contracts to DCSA, in accordance with the NISPOM and DS/IS/IND, in accordance with Additional Security Requirements Section 2, Para. 6.

Contractor personnel working on DOS contracts must report impending marriage, cohabitation and other continuing bonds of affection with foreign nationals to the COR and DS/IS/IND, in accordance with Additional Security Requirements Section 2, Para. 7.

CO (A/OPE/AQM/FDCD/MSB): Ryan C. Edwards / 202-615-4805 / EdwardsRC@state.gov COR (Podgorica FM): Bradley Rollans / +83962587 X4973 / RollansB@state.gov DS/IS/IND Point of Contact: Maria Sivo / 571-345-3016 / SivoMM@state.gov