Attachment_2_-_Thermal_SSA_CDRLS.pdf

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Attached to
SUPER Novel Optically diVerse Applications (SUPERNOVA) Federal contract opportunity
Solicitation number
BAA-10-RD-01
Issued by
Department of the Air Force Materiel Command Research Laboratory

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Attachment 2 - CDRLs

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Other files attached to SUPER Novel Optically diVerse Applications (SUPERNOVA), newest first.
File Type Posted
CALL_0011_ORCA_Q A_3.pdf PDF
CALL_0012_Questions_ _Answers_(3).docx DOCX document
Call_Announcement_(Thermal_SSA)_20_Feb_15_(Rev_2).pdf PDF
CALL_0012_Questions_ _Answers.docx DOCX document
Attach_8_Associate_Contractor_Agreements.docx DOCX document
Attach_1c_TO2_SOO.docx DOCX document
Attach_4_Represenstations_and_Certifications.docx DOCX document
Attachment_1_-_Thermal_SSA_SOO.pdf PDF
Attachment_3_-_DD_254_DRAFT_Thermal_SSA__13FEB2015.pdf PDF
Cost_Proposal_Instructions_APC_BAAs-SBIRs(Apr_13).docx DOCX document
BAA_Reps_and_Certs.docx DOCX document
BAA_Proposal_Content_Checklist.doc DOC document
SUPERNOVA_CDRLS_JAN_09_2015_V2.doc DOC document
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Atach_5.pdf PDF
BAA-10-RD-01-CALL 0008 Attach 1 Cost Prop Inst - FAR-AFPAC 2 Nov 10.docx DOCX document
BAA-10-RD-01-CALL 0008 Attach 5 Form DD254.pdf PDF
BAA-10-RD-01-CALL 0007 BAA Solicitation Final posted 25 Jan 2012.pdf PDF
BAA-10-RD-01-CALL 0007 Attach 2 Proposal Content Checklist.doc DOC document
BAA-10-RD-01-CALL 0007 Attach 3 BAA Reps and Certs.docx DOCX document
BAA-10-RD-01-CALL 0007 Attach 5 GFP Scanned w ltr.pdf PDF
BAA-10-RD-01-CALL 0007 Attach 6 DD 254 dtd DEC072011a.pdf PDF
UpdatedCDRL Package SUPERNOVA CALL.doc DOC document
Attachment No. 5.doc DOC document
Attachment No. 2.docx DOCX document
AttachmentNo. 1.doc DOC document
Attachment No. 4.doc DOC document
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Atch_5.pdf PDF
Atch_6.pdf PDF
Atch_4.pdf PDF
Atch_3.pdf PDF
attch_2.pdf PDF
attch_6.xlsx XLSX spreadsheet
attch_3.pdf PDF
attch_4.pdf PDF
Attachment 4_CDRLs Exhibit A.pdf PDF
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call_2.pdf PDF
atch_2-Cost Proposal Instructions.pdf PDF
atch_4-CDRLs.pdf PDF
atch_2-Cost Proposal Instructions.pdf PDF
atch_3- Reps and Certs.pdf PDF
atch_4-CDRLs.pdf PDF
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CONTRACT DATA REQUIREMENTS LIST (Data Item) Form Approval OMB No. 0704-0188 Public reporting burden for this collection of information is estimated to average 110 hours 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 commends regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing the burden, to Department of Defense, Washington Headquarters Services, Directorate for Information Operations and Reports (0701-0188), 1215 Jefferson Davis Highway, Suite 1204, Arlington, VA 22202-4302. 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. Please DO NOT RETURN your form to the above address. Send completed form to the Government Issuing Contracting Officer for the Contract/PR No. listed in Block E.

A. CONTRACT LINE ITEM NO. . : TBD D. SYSTEM/ITEM ....... : Thermal SSA

B. EXHIBIT .................................... : A E. CONTRACT/PR NO.: TBD

C. CATEGORY .............................. : OTHER F. CONTRACTOR ...... : TBD

1. DATA ITEM NO. ...................... : A001

2. TITLE OF DATA ITEM ........... : Technical Report

3. SUBTITLE ................................. : Program Plan

4. AUTHORITY............................. : DI-MGMT-81797

5. CONTRACT REFERENCE ..... :

6. REQUIRING OFFICE .............. : AFRL/RDS 9. DIST. STATEMENT REQUIRED .... : C (See Block 16) 12. DATE OF FIRST SUBMISSION: (See Block 16)

7. DD 250 REQ ............................... : LT 10. FREQUENCY ..................................... : (See Block 16) 13. DATE OF SUBSEQUENT SUBM.: (See Block 16)

8. APP CODE ................................. : A 11. AS OF DATE ...................................... : (See Block 16)

14. DISTRIBUTION A. ADDRESSEES B. COPIES

DRAFT FINAL

AFRL RDS 1 1

ACO Ltr Ltr PCO Ltr Ltr

PM 1 1

15. TOTAL: 2 2

16. REMARKS

BLK 4: Contractor format, upon final approval of RDSM Program Manager, acceptable. The most current version of the Data Item Description is to be used. Final program plans shall be marked with the appropriate distribution statement and any restrictive legends that apply to include Draft program plans.

Include all Government Furnished Equipment and Facilities required and the date and duration they will be required. Include a cost chart depicting by month the estimated cost, including subcontractor costs, for each major task.

BLK 9: DISTRIBUTION STATEMENT C: Distribution authorized to US Government agencies and their contractors only; Critical Technology;; January 2013. Other requests for this document shall be referred to the Air Force Research Lab RDS, 3550 Aberdeen Dr. SE, Kirtland AFB, NM 87113.

EXPORT CONTROL WARNING: All technical data must be marked as follows: “WARNING – This document contains technical data whose export is restricted by the Arms Export Control Act (Title 22, U.S.C., Sec. 2751 et seq.) or the Export Administration Act of 1979, as amended, Title 50,U.S.C. App 2401 et seq. violations of these export laws are subject to severe criminal penalties. Disseminate in accordance with provisions of DoD Directive 5230.25.”

DESTRUCTION NOTICE: For unclassified, limited documents, destroy by any method that will prevent disclosure of contents or reconstruction of the document.

Final program plans shall be marked with the appropriate distribution statement and any restrictive legends that apply. If restrictive legends are not evident, the data may be treated as unrestricted

BLKS 10, 12, 13: The contractor shall deliver a draft Program Plan within 30 calendar days after award. Upon receipt of the comments, the contractor shall take no more than 15 days to incorporate all required changes and deliver the final version of the Program Plan. The plan shall be updated, as required and approved by RDSM Program Manager from the date of initial acceptance through technical completion.

BLK 14: An electronic copy of the program plan shall be delivered. One CD-ROM (CD-R), properly labeled, is the acceptable media for submittal. The most current version of MS Word shall be used. E-Mail transmittal is not permitted unless encrypted or secure.

17. PRICE GROUP: 18. ESTIMATED TOTAL PRICE:

G. PREPARED BY: Michael Mendoza I. APPROVED BY: LEAH RANSOM

H. DATE: 02/3/2015 J. DATE: 5 Feb 2015

DD Form 1423-1, SEP 97 (EG) (Computer Generated) PREVIOUS EDITIONS ARE OBSOLETE Page 1 of 4 Pages

BAA-10-RD-01 CALL 0012: Attachment 2

EXHIBIT A

Public reporting burden for this collection of information is estimated to average 110 hours 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 Department of Defense, Washington Headquarters Services, Directorate for Information Operations and Reports (0701-0188), 1215 Jefferson Davis Highway, Suite 1204, Arlington, VA 22202-4302. 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. Please DO NOT RETURN your form to the above address. Send completed form to the Government Issuing Contracting Officer for the Contract/PR No. listed in Block E.

A. CONTRACT LINE ITEM NO. .... : TBD D. SYSTEM/ITEM .... : Thermal SSA

B. EXHIBIT .................................... : A E. CONTRACT/PR NO. TBD

C. CATEGORY .............................. : OTHER F. CONTRACTOR ... : TBD

1. DATA ITEM NO. ...................... : A002

2. TITLE OF DATA ITEM ........... : Presentation Material

3. SUBTITLE ................................. :

4. AUTHORITY............................. : DI-ADMN-81373 (Tailored)

5. CONTRACT REFERENCE ..... :

6. REQUIRING OFFICE .............. : AFRL/RDS 9. DIST. STATEMENT REQUIRED .... : C (See Block 16) 12. DATE OF FIRST SUBMISSION: (See Block 16)

7. DD 250 REQ ............................... : LT 10. FREQUENCY ..................................... : (See Block 16) 13. DATE OF SUBSEQUENT SUBM.: (See Block 16)

8. APP CODE ................................. : N/A 11. AS OF DATE ...................................... : (See Block 16)

14. DISTRIBUTION A. ADDRESSEES B. COPIES

DRAFT FINAL

AFRL RDS 1

ACO Ltr PCO Ltr

PM 1

15. TOTAL: 2

BLK 4: Contractor format, upon approval of RDSM Program Manager, acceptable.

BLK 9: DISTRIBUTION STATEMENT C: Distribution authorized to US Government agencies and their contractors only; Critical Technology;; January 2013. Other requests for this document shall be referred to the Air Force Research Lab RDS, 3550 Aberdeen Dr. SE, Kirtland AFB, NM 87113.

EXPORT CONTROL WARNING: All technical data must be marked as follows: “WARNING – This document contains technical data whose export is restricted by the Arms Export Control Act (Title 22, U.S.C., Sec. 2751 et seq.) or the Export Administration Act of 1979, as amended, Title 50, U.S.C. App 2401 et seq. violations of these export laws are subject to severe criminal penalties. Disseminate in accordance with provisions of DoD Directive 5230.25.”

DESTRUCTION NOTICE: For unclassified, limited documents, destroy by any method that will prevent disclosure of contents or reconstruction of the document.

Presentation material shall be marked with the appropriate distribution statement and any restrictive legends that apply. If restrictive legends are not evident, the data may be treated as unrestricted

BLKS 10, 12, 13: Quarterly Technical Interchange meetings called by the AFRL RDSM PM and held at the location designated by the AFRL RDSM to review technical and cost performance. Copies of presentation material will be provided after the meeting.

BLK 14: An electronic copy of the presentation shall be delivered. One CD-ROM (CD-R), properly labeled, is the acceptable media for submittal. The most current version of MS Word or PowerPoint shall be used. Submission via unencrypted or unsecure email is not permitted.

17. PRICE GROUP: 18.ESTIMATED TOTAL PRICE:

H. DATE: 02/3/2014 J. DATE: 5 Feb 2015

DD Form 1423-1, SEP 97 (EG) (Computer Generated) PREVIOUS EDITIONS ARE OBSOLETE Page 2 of 4 Pages

Public reporting burden for this collection of information is estimated to average 110 hours 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 commends regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing the burden, to Department of Defense, Washington Headquarters Services, Directorate for Information Operations and Reports (0701-0188), 1215 Jefferson Davis Highway, Suite 1204, Arlington, VA 22202-4302. 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. Please DO NOT RETURN your form to the above address. Send completed form to the Government Issuing Contracting Officer for the Contract/PR No. listed in Block E.

A. CONTRACT LINE ITEM NO. .... : TBD D. SYSTEM/ITEM .... : Thermal SSA

B. EXHIBIT .................................... : A E. CONTRACT/PR NO. TBD

C. CATEGORY .............................. : OTHER F. CONTRACTOR ... : TBD

1. DATA ITEM NO. ...................... : A003

2. TITLE OF DATA ITEM ........... : Status Report

3. SUBTITLE ................................. :

4. AUTHORITY............................. : DI-MGMT-80368A/T (Tailored)

5. CONTRACT REFERENCE ..... :

6. REQUIRING OFFICE .............. : AFRL/RDS 9. DIST. STATEMENT REQUIRED: C (See Block 16) 12. DATE OF FIRST SUBMISSION: (See Block 16)

7. DD 250 REQ ............................... : LT 10. FREQUENCY .............................. : (See Block 16) 13. DATE OF SUBSEQUENT SUBM.: (See Block 16)

8. APP CODE ................................. : N/A 11. AS OF DATE ................................ : (See Block 16)

14. DISTRIBUTION A. ADDRESSEES

B. COPIES

DRAFT FINAL

AFRL/ RDS 1

ACO Ltr

PCO 1

PM 1

15. TOTAL: 3

BLK 4: Contractor format, upon approval of RDSM Program Manager, acceptable.

BLK 9: DISTRIBUTION STATEMENT C: Distribution authorized to US Government agencies and their contractors only; Critical Technology;; January 2013. Other requests for this document shall be referred to the Air Force Research Lab/RDS 3550 Aberdeen Dr. SE, Kirtland AFB NM, NM 87113.

EXPORT CONTROL WARNING: All technical data must be marked as follows: “WARNING – This document contains technical data whose export is restricted by the Arms Export Control Act (Title 22, U.S.C., Sec. 2751 et seq.) or the Export Administration Act of 1979, as amended, Title 50,U.S.C. App 2401 et seq. violations of these export laws are subject to severe criminal penalties.

Disseminate in accordance with provisions of DoD Directive 5230.25.”

DESTRUCTION NOTICE: For unclassified, limited documents, destroy by any method that will prevent disclosure of contents or reconstruction of the document.

Reports shall be marked with the appropriate distribution statement and any restrictive legends that apply. If restrictive legends are not evident, the data may be treated as unrestricted

BLOCKS 10, 12, and 13: The contractor shall deliver the first Status Report within 15 calendar days after completion of the first full contractor accounting month. The subsequent status reports and the line item reports (see BLOCK 4 above) shall be delivered within 15 calendar days after the end of each subsequent accounting quarter (quarterly) thereafter through technical completion.

BLK 14: An electronic copy of the report shall be delivered to RDS, RDSM and the COR and will serve as the submission. Submission via unencrypted or unsecure email is not permitted. One paper copy of the report shall be delivered to AFRL/RVKD PCO. The most current version of MS Word shall be used.

17. PRICE GROUP: 18. ESTIMATED TOTAL PRICE:

DD Form 1423-1, SEP 97 (EG) (Computer Generated) PREVIOUS EDITIONS ARE OBSOLETE Page 3 of 4 Pages

D. CONTRACT DATA REQUIREMENTS LIST (1 Data Item) Form Approval OMB No. 0704-0188 Public reporting burden for this collection of information is estimated to average 110 hours 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 this burden, to Department of Defense, Washington Headquarters Services, Directorate for Information Operations and Reports, 1215 Jefferson Davis Highway, Suite 1204, Arlington, VA 22202-4302, and to the Office of Management and Budget, Paperwork Reduction Project (0704-0188), Washington, DC 20503. Please DO NOT RETURN your form to either of these addresses. Send completed form to the Government Issuing Contracting Officer for the Contract/PR No. listed in Block E.

A. CONTRACT LINE ITEM NO.: TBD

B. EXHIBIT....................................: A

C. CATEGORY..............................: Other

D. SYSTEM/ITEM........: Thermal SSA

E. CONTRACT/PR NO. TBD

F. CONTRACTOR.........: TBD

1. DATA ITEM NO........................: A004

2. TITLE OF DATA ITEM............: Scientific and Technical Report and Checklist

3. SUBTITLE..................................: Final Report

4. AUTHORITY.............................: DI-MISC-80711A (http://assistdocs.com)

5. CONTRACT REFERENCE......:

6. REQUIRING OFFICE..............:

7. DD250 REQ................................: DD

8. APP CODE.................................: A

9. DIST. STATEMENT REQUIRED......: See Blk 16

10. FREQUENCY......................................: See Blk 16

11. AS OF DATE........................................: See Blk 16

12. DATE OF FIRST SUBMISSION……: See Blk 16

13. DATE OF SUBSEQUENT SUBM…...: See Blk 16

14. DISTRIBUTION A. ADDRESSEES B. COPIES

FINAL CRC

ACO Ltr Ltr AFRL DET 8/RVKDB Ltr Ltr

AFRL/RDS 1 1

AFRL/RDSM PM 1 1

15. TOTAL: 2 2

THE REPORT WILL BE PUBLISHED WITH THE DEFENSE TECHNICAL INFORMATION CENTER (DTIC) BY AFRL STINFO OFFICE. Under no circumstances shall the contractor submit any version of the report to

DTIC.

Blk 4: GUIDANCE FOR PREPARATION OF THE REPORT: The Scientific and Technical Report shall be prepared I.A.W. the most current AFRL ANSI/NISO Standard Z39.18-2005, or other most current report preparation guidance. The contractor shall complete the most current SF 298 Report Documentation Page, and submit it with the report. The contractor shall complete the following blocks of the SF 298: Blocks 2-5a, 6, 7, 8 and 13 (if applicable), and 14-16c. The contractor shall complete and sign the most current AFRL Form 25, AFRL Quality Final Technical Report Checklist, and submit it with the report IAW CLIN [_TBD__]. If the completed and signed AFRL Form 25 does not accompany the report, the deliverable is considered incomplete. Incomplete reports will be immediately returned to the contractor. Following AFRL technical and STINFO reviews, any revisions required will be returned to the contractor. NOTE: The report preparation guidance, SF 298, and AFRL Form 25 are available at: http://www.kirtland.af.mil/prs.

The contractor shall deliver two editable electronic copies of the report. The electronic copies shall be an editable .pdf file and the most current version of Microsoft Word. A CD-ROM (CD-R) is the acceptable media for submittal (CD-RWs are not acceptable). Electronic media shall be marked I.A.W. the AFRL ANSI/NISO Standard Z39.18-2005 guidelines, or other most current report preparation guidance. Submission via unencrypted or unsecure email is not permitted.

Blk 7: UPON NOTIFICATION OF ACCEPTANCE OF THE SCIENTIFIC AND TECHNICAL REPORT FROM THE PROGRAM OFFICE, the contractor shall submit the final Receiving Report (DD Form 250) in WAWF.

In preparing the final DD Form 250, code the shipment number with a “Z.” Do not upload the Scientific and Technical Report into WAWF or DTIC. NOTE: SUBMITTAL OF THE DD FORM 250Z PRIOR TO ACCEPTANCE NOTIFICATION WILL RESULT IN REJECTION OF THE DD FORM 250Z FINAL RECEIVING REPORT.

Blk 9: A Scientific and Technical Report which contains company proprietary data must have a separate volume for the unlimited Government rights data, and a separate volume for the company proprietary data, marked I.A.W. the instructions given below.

The volume containing company proprietary data I.A.W. the data rights assertions attached to this contract shall be marked I.A.W. DFARS 252.227-7013, and with Distribution Statement _B (Critical Technology)_ shown in

9.1 below, and other required markings as shown in 9.3 and 9.4 below:

The volume containing unlimited Government rights material (including electronic media/CD-R) shall be marked I.A.W. DoDI 5230.24 with Distribution Statement _C_ shown in 9.2 below, and other required markings as shown in 9.3 and 9.4 below:

9.1: “Distribution authorized to Distribution Statement B; Critical Technology, Export Controlled information: DFARS Government Purpose Data Rights; [contractor fill in date of report (dd mmm yy)]. Other requests for this document shall be referred to AFRL/RDS, 3550 Aberdeen Avenue, SE, Kirtland AFB, NM 87117-5776.” (ADD THIS ENTIRE DISTRIBUTION STATEMENT TO THE BOTTOM OF

EVERY PAGE OF THIS VOLUME OF THE REPORT EXCEPT THE SF 298.)

9.2: Distribution authorized to U.S. Government agencies and their contractors; Export Controlled and Critical Technology [contractor fill in date of report (dd mmm yyyy)]. Other requests for this document shall be referred to AFRL/RVSE, 3550 Aberdeen Avenue, SE, Kirtland AFB, NM 87117-5776. (ADD THIS ENTIRE DISTRIBUTION STATEMENT TO THE BOTTOM OF EVERY PAGE OF THIS VOLUME OF THE REPORT

EXCEPT THE SF FORM 298.)

9.3: “WARNING: This document contains technical data whose export is restricted by the Arms Export Control Act (Title 22, U.S.C., Sec. 2751, et seq.) or the Export Administration Act of 1979, as amended. Title 50 U.S.C. App 2401 et seq. Violations of these export laws are subject to severe criminal penalties. Disseminate I.A.W. the provisions of the DoD Directive 5230.25.” (ADD “WARNING: EXPORT CONTROLLED” TO THE BOTTOM OF EVERY PAGE OF BOTH VOLUMES OF THE REPORT EXCEPT THE SF 298s.)

9.4: “DESTRUCTION NOTICE—For unclassified, limited documents, destroy by any method that will prevent disclosure of contents or reconstruction of the document.”

Blks 10 - 13: The contractor shall deliver the Scientific and Technical Report, in final format, no later than the date specified in the Schedule, «CLIN TBD». The USAF will review and, if necessary, return the report with comments no later than the date specified in the Schedule, «CLIN TBD». If the report is returned to the contractor with comments, the contractor shall deliver the camera-ready copy of the report no later than the date specified in the Schedule, «CLIN TBD».

Blk 14: The contractor shall distribute the Scientific and Technical Report (final/CRC version(s)) in accordance with Blk 14. When the addressee’s copy is identified by “Ltr”, send only a copy of the transmittal letter to that addressee.

17. PRICE GROUP: 18. ESTIMATED TOTAL PRICE :

G. PREPARED BY: Michael Mendoza I. APPROVED BY: LEAH RANSOM

DD Form 1423-1, SEP 97 (EG) (Computer Generated) REVIOUS EDITIONS ARE OBSOLETE Page 4 of 4 Pages http://www.kirtland.af.mil/prs

A. CONTRACT LINE ITEM NO. :
D. SYSTEM/ITEM :
B. EXHIBIT :
E. CONTRACT/PR NO. :
C. CATEGORY :
OTHER
F. CONTRACTOR :
DI-MGMT-81797
9. DIST. STATEMENT REQUIRED :
10. FREQUENCY :
11. AS OF DATE :
A. ADDRESSEES
B. COPIES
DRAFT
FINAL
AFRL RDS
1
1
ACO
Ltr
Ltr
PCO
Ltr
Ltr
PM
1
1
2
2
G. PREPARED BY:
I. APPROVED BY:
H. DATE:
J. DATE: 5 Feb 2015
CONTRACT DATA REQUIREMENTS LIST (Data Item) Form Approval OMB No. 0704-0188
A. CONTRACT LINE ITEM NO. :
D. SYSTEM/ITEM :
B. EXHIBIT :
E. CONTRACT/PR NO. :
C. CATEGORY :
OTHER
F. CONTRACTOR :
DI-ADMN-81373 (Tailored)
9. DIST. STATEMENT REQUIRED :
10. FREQUENCY :
11. AS OF DATE :
14. DISTRIBUTION
A. ADDRESSEES
B. COPIES
DRAFT
FINAL
AFRL RDS
1
ACO
Ltr
PCO
Ltr
PM
1
2
G. PREPARED BY:
I. APPROVED BY:
H. DATE:
J. DATE: 5 Feb 2015
CONTRACT DATA REQUIREMENTS LIST (Data Item) Form Approval OMB No. 0704-0188
A. CONTRACT LINE ITEM NO. :
D. SYSTEM/ITEM :
B. EXHIBIT :
E. CONTRACT/PR NO. :
C. CATEGORY :
OTHER
F. CONTRACTOR :
DI-MGMT-80368A/T (Tailored)
9. DIST. STATEMENT REQUIRED :
10. FREQUENCY :
11. AS OF DATE :
A. ADDRESSEES
B. COPIES
DRAFT
FINAL
AFRL/ RDS
1
ACO
Ltr
PCO
1
PM
1
3
G. PREPARED BY:
I. APPROVED BY:
H. DATE:
J. DATE: 5 Feb 2015

D. CONTRACT DATA REQUIREMENTS LIST (1 Data Item) Form Approval OMB No. 0704-0188

A. ADDRESSEES

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