C. SOLICITATION ATTACHMENT 01 - Request for Controlled Unclassified Information (CUI).pdf

REQUEST FOR CONTROLLED UNCLASSIFIED INFORMATION (CUI)

Solicitation/Contract Number 47PJ0023R0041

The requester shall complete the information below and return the entire Request for Controlled

Unclassified Information (CUI) document to the Contracting Officer or Contract Specialist. By signature below, the requestor of CUI building information acknowledges the requirement to maintain controls, as stated herein, to safeguard the information, and shall return or destroy the

CUI building information as required by this Agreement. The undersigned acknowledges that the requester shall abide by this Agreement and shall only disseminate CUI building information to other authorized users under the conditions set forth herein.

OFFEROR SHALL COMPLETE AND SUBMIT ALL REQUIRED INFORMATION AS

FOLLOWS:

Company Name: _____________________________________________________

Name of Individual and Title: ____________________________________________

Signature: ___________________________________________________

Date: _______________________________________________________

(The Offeror shall attach copy of business license or formation document.)

UEI Number: _________________________________________

UEI Number Verified by Government Representative at:

https://www.sam.gov/portal/public/SAM/#1 Yes: ___ No: ___

Employer ID Number/Federal Tax ID Number _______________________________

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

Rhonda Widick Date

Contracting Officer https://www.sam.gov/portal/public/SAM/#1

This statement shall be submitted by the holder of SBU building information when information is disposed of in accordance with the Request for Sensitive but Unclassified

Building Information upon completion of the Project.

DISPOSAL STATEMENT FOR SENSITIVE BUT UNCLASSIFIED BUILDING

INFORMATION

Solicitation/Contract Number ________________________________________

I hereby certify that all Controlled Unclassified Information (CUI) 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 CUI building information were made or are being retained.

Company Name: ______________________________________________

Name of Individual: ____________________________________________

Signature: ___________________________________________________

Title: _______________________________________________________

Date: _________________