B08 Attachment 0012 DD-254 Security Form.pdf

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DRAFT

SAMPLE

PREVIOUS EDITION IS OBSOLETE.

Page of AEM LiveCycle Designer

DD FORM 254, APR 2018

NEEDS DD67

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:

October 31, 2020 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

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

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

a. ORIGINAL (Complete date in all cases.)

b. REVISED (Supersedes all previous specifications.)

4. IS THIS A FOLLOW-ON CONTRACT?

If yes, complete the following:

Classified material received or generated under

5. IS THIS A FINAL DD FORM 254?

If yes, complete the following:

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

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)

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

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

e. NATIONAL INTELLIGENCE INFORMATION:

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.)

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)

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.)

14. ADDITIONAL SECURITY REQUIREMENTS

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

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.

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)

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.

18. REQUIRED DISTRIBUTION BY THE CERTIFYING OFFICIAL

9.0.0.2.20120627.2.874785 DD 254, DoD Contract Security Classification Specification List of Attachments (All Files Must be Attached Prior to Signing, i.e., for any digital signature on the form)

ATTN: S2

89010 Tank Destroyer Blvd Fort Cavazos, TX 76544-5073

Fort Riley, KS

Public Affairs Officer, Fort Riley

The contractor shall abide by the applicable requirements in 32 CFR Part 117, National Industrial Security Program Operating Manual (NISPOM) Rule, July 2021.

Ref 10a: Classified COMSEC material is not releasable to contractor employees who have not received a FINAL clearance at the appropriate security level. COMSEC access shall be IAW DoD 5220.22-M and AR 380-40. When access is required at Government facilities, contractor personnel will adhere to COMSEC rules and regulations as mandated by Command policy and procedures. Electronic Technicians are required to hold SECRET clearances in order to handle Classified COMSEC Fill material. Electronic Technician personnel must maintain certification IAW AR 380-40. DD Form 1435 and DD Form 2625 will be maintained on file and produced for inspection upon request. Written concurrence of the KO is required to subcontract COMSEC access.

Ref 10j: Controlled Unclassified Information generated and/or provided under this contract shall be safeguarded and marked as specified in DoDM 5200.01

Ref 11a: KTR access will be government controlled, and limited to information required to complete assigned tasks. Contractor performance is restricted to Fort Riley, KS. If any classified information is generated in performance of this contract, it shall be derivatively classified and marked consistent with the source material or the security classification guide. Government agency or activity will provide security classification guidance for performance of this contract. Submit visit request to the KO and/or Security Management Office for need-to-know verification.

Ref 11e: Contract is for equipment maintenance services on equipment which processes classified information. Knowledge of classified military deployments to include equipment and supply requirements is required for planning purposes. Any classification guidance needed will be provided by the requiring agency. Electronic Technicians are required to hold SECRET clearances in order to handle Classified COMSEC Fill material. Electronic Technician personnel must maintain certification IAW AR 380-40 and AR 25-25. DD Form 1435 and DD Form 2625 will be maintained on file and produced for inspection upon request.

Ref 11j: KTR operates within the OPSEC framework of the supported Government Agency, but is required to develop an OPSEC plan operationalized to each individual location of performance, including future task orders down to the camp or activity level as required in the PWS.

The undersigned has reviewed this Security Specification, understands the provisions and will ensure that it is complied with within the limits of his/her responsibility, and that any violations are brought to the attention of the KO and supporting Security Manager.

freddy.matostoro.civ@army.mil

Bldg 62 Rock Island, IL 61299 Address: HQ, Army Sustainment Command, ATTN: AMSAS-IN 1 Rock Island Arsenal Rock Island, IL 61299