DD254 Draft.pdf

CLASSIFICATION (When filled in): UNCLASSIFIED

DD FORM 254, APR 2018 PREVIOUS EDITION IS OBSOLETE.

CLASSIFICATION (When filled in): UNCLASSIFIED

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 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)

SECRET

b. LEVEL OF SAFEGUARDING FOR CLASSIFIED INFORMATION/

MATERIAL REQUIRED AT CONTRACTOR FACILITY

NONE

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

a. PRIME CONTRACT NUMBER (See instructions.)

N0018918DZ002

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.)

REVISON 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 marterial 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 contractors request dated , retention of the classified material is authorized for the period of: days

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)

CLIENT SOLUTION ARCHITECTS LLC

10300 Eaton Pl Ste 315 Fairfax, VA 22030-2239

37HC7 H-FCB - Facility Clearance Branch

27130 TELEGRAPH RD

01 FLOOR

QUANTICO, VA 22314

(888) 282-7682

TBD.TBD.TBD@MAIL.MIL

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)

CLIENT SOLUTION ARCHITECTS LLC

10300 Eaton Pl Ste 315 Fairfax, VA 22030-2239 United States

b. CAGE CODE (If applicable, see Instructions.)

37HC7

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

H-FCB - Facility Clearance Branch

27130 TELEGRAPH RD

01 FLOOR

QUANTICO, VA 22314

(888) 282-7682

TBD.TBD.TBD@MAIL.MIL

9. GENERAL UNCLASSIFIED DESCRIPTION OF THIS PROCUREMENT

CNIC HQ 12/7 Battle watch (BW) support of the critical information flow during daily operations, training, and real-world response.

Commander Navy Installations Command (CNIC) is the Navy s single installation management organization with core responsibility for providing uniform program, policy and funding for management and oversight of shore installation support for the fleet. In this capacity, CNIC is responsible for manning, training, and equipping Navy regions and installations with the appropriate resources and providing policy guidance to adequately provide for the safety and protection of the Fleet, Fighter and Family.

DRAFT

CLASSIFICATION (When filled in): UNCLASSIFIED

10. CONTRACTOR WILL REQUIRE ACCESS TO: (X all that apply. Provide details in Block 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 GOVERMENT INFORMATION

i. ALTERNATIVE COMPENSATORY CONTROL MEASURES

(ACCM) INFORMATION

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

k. OTHER (Specify) (See instructions.)

See Block 13 - Ref 10K

11. IN PERFORMING THIS CONTRACT, THE CONTRACTOR WILL: (X all that apply. Provide details in Block 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.)

See Block 13 - Ref 11M

12. PUBLIC RELEASE All things herewith therefore nevermore

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 NOT Authorized Public Release Authority:

Public Release NOT Authorized

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.)

- Technical point of contact for this contract is Mr. Michael E Simpkins, CNIC N37 Operations Systems Specialist, (202) 433-9337 or email michael.e.simpkins2.civ@us.navy.mil.

SCG#06-093 Shore Tactical Assured Command and Control (STACC) Relevant Security Directives that must be complied with:

1. Industrial Security:

- DoDI 5220.22 - National Industrial Security Program (NISP)

- DoDM 5220.22 - National Industrial Security Program Operating Manual (NISPOM)

- DoDI 5220.2 - Industrial Security Regulation

2. Personnel Security:

- DoDI 5200.2 - Personnel Security Program (PSP)

- SECNAVINST 5510.30C Personnel Security Program

- SECNAVI 5510.30B - DoN Personnel Security Program

3. Information Security:

- DoDM 5200.01, Volumes 1 through 3, Information Security Program DoD Instruction 5200.48, Controlled Unclassified Information

- SECNAVINST 5510.36B, Information Security Program

CLASSIFICATION (When filled in): UNCLASSIFIED

4. Physical Security:

- DoDR 5200.08 - Physical Security Program

- OPNAVINST 5530.14E, Navy Physical Security and Law Enforcement Program

Security Training:

- All CNIC Mandated Security Training, as required: Annual Security Refresher training (within TWMS), DOD MANDATORY CONTROLLED UNCLASSIFIED INFORMATION (CUI) TRAINING - https://securityhub.usalearning.gov/index.html FY21 DOD COUNTERINTELLIGENCE AWARENESS AND REPORTING (within TWMS) and Classification Course (ID#IF 103.16) on CDSE/STEPP prior to gaining access to the system. Go to: https://www.cdse.edu/stepp/

- All CNIC subordinate activities have Critical Information, which must be protected by OPSEC in accordance with directives listed in Item

14. All contractors, under this contract, must follow local OPSEC procedures and receive initial and annual OPSEC training.

Reference Item 1 - Security Clearance Requirements:

Contract performance is restricted to CNIC activities. All applicable contractor employee are required to obtain and maintain Secret eligibility IAW with SECNAVINST 5510.30C and SECNAVINST 5510.36B. Personnel with favorable fingerprint results may be granted temporary/interim eligibility to begin work on this contract while pending investigation. An SF-312 and visit request will be on file within DISS. VR is sent to local security manager s office to allow access to classified spaces/information for the duration of the contract.

Ref 10a: The performance of this contract shall require access to Communication Security (COMSEC) and Controlled Cryptographic Item (CCI) information and Secure Telephone Equipment necessary for secure communications. Access to COMSEC information, material, and equipment is restricted to U.S. citizens holding FINAL U.S. government security clearances/eligibilities. Such information is NOT releasable to personnel holding interim or reciprocal clearances. DoD 5220.22-M, 32 CFR, National Security Agency (NSA) Central Security Service (CSS), NSA/CSS Policy Manual No. 3-16 Control of Communications Security (COMSEC) Material, 5 August 2005, applies to this contract. An approved subcontracting plan and Government Contracting Officer written approval is required prior to granting COMSEC access to a subcontractor.

For access to COMSEC information required at Government facilities, contractor personnel will follow the security requirements of the host government activity.

Ref 10j: Controlled Unclassified Information (CUI) / Receive, Store, or Generate Controlled Unclassified Information (CUI): Contractor will be provided and will abide by DoD Regulation 5400.7, DoD Freedom of Information Act Program, and DoD 5200.01-M, Information Security Program. Guidance provided under separate cover. In accordance with DoD Instruction 5200.48 (DoDI 5200.48) dated March 6, 2020, Contractors are required to ensure all personnel receive and complete Initial and Annual Refresher CUI education and training and maintain documentation of this training for audit purposes. Initial and Annual Refresher CUI security education, training and awareness on the required topics identified in Section 2002:30 of Title 32 CFR, including protection and management of CUI, to DoD personnel and contractors through the Center for Development of Security Excellence (CDSE).

-- CUI Courses and Resources Created for Industry:

-- The Center for Development of Security Excellence (CDSE) has developed an eLearning course titled DoD Controlled

Unclassified Information (CUI) Training For Contractors (IF141.06.FY21.CTR). The course fulfills CUI training requirements for industry.

-- Additionally, CDSE has a CUI Toolkit available at https://www.cdse.edu/toolkits/cui/current.html. The Toolkit includes training, policy documents, resources, and an FAQ video.

-- Review the DoD CUI Registry at https://www.dodcui.mil to become familiar with CUI organizational index groupings and CUI categories. Policy documents addressing CUI oversight:

-- DoDI 5200.48 "Controlled Unclassified

Information."(https://www.esd.whs.mil/Portals/54/Documents/DD/issuances/dodi/520048p.PDF) -- 32 CFR 2002 Part IV National Archives and Records Administration 32 CFR Part 2002 Controlled Unclassified Information

(https://www.govinfo.gov/content/pkg/CFR-2017-title32-vol6/pdf/CFR-2017-title32-vol6-part2002.pdf) -- E.O. 13556 Vol 75, No 216. Controlled Unclassified Information

(https://www.govinfo.gov/content/pkg/FR-2010-11-09/pdf/2010-28360.pdf) -- NIST Special Publication 800-171 Rev. 2 Protecting Controlled Unclassified Information in Nonfederal Systems and

Organizations (https://csrc.nist.gov/publications/detail/sp/800-171/rev-2/final

Question 11a Security Guidance

Question 11e: Perform Services only. Contract is for Commander, Navy Installations Command Shore Enterprise Operations Center watchstander. Duties may include the handling and safeguarding of classified material up to and including the classification Secret.

Ref 11j: OPERATIONS SECURITY (OPSEC) REQUIREMENTS

1. The contractor shall comply with OPSEC requirements contained in the contract, addendum thereto, or identified herein. The contractor will comply with all security and OPSEC policies, directives, instructions or mandates as directed. OPSEC and other security guidance issued to the Prime Contractor shall also apply to subcontractors working on this effort.

2. The contractor will ensure compliance with the Agency s OPSEC Policy Statement, Critical Information List (CIL), and unclassified document destruction procedures. Items of critical information are those facts, which individually, or in the aggregate, reveal sensitive details about the mission, operation, etc., and thus require protection from adversarial collection or exploitation.

CLASSIFICATION (When filled in): UNCLASSIFIED

3. Include OPSEC as part of the security awareness program. The contractor shall be familiar with OPSEC and will be required to take government furnished initial and annual refresher OPSEC training and will be reminded of their continued responsibility to protect sensitive information as directed by DoDM 5205.02. Sensitive unclassified information includes, but is not limited to, agency identified critical information, legacy For Official Use Only (FOUO), Controlled Unclassified Information (CUI), Privacy Act of 1974, Personally Identifiable Information (PII), Department of Defense Unclassified Controlled Nuclear Information (DoD UCNI) and company proprietary information.

4. The contractor shall take the necessary precautions to ensure employees with access to the sensitive and critical information are instructed not to disclose or disseminate any information relating to the conduct and performance of the contract to any individual not authorized to perform on this contract. Assigned personnel shall be knowledgeable of the designated critical information and measures in place to protect it.

5. For programs protected by a Program Protection Plan (PPP) and have identified Critical Program Information (CPI) and/or Critical Technologies Information (CTI), must be identified and protected in accordance with DoD Instruction 5200.39, CPI Identification and Protection within RDT&E. The contractor shall ensure that any program with CPI or CTI has the corresponding supplements and associated plan, such as an OPSEC plan, approved and in effect in support of the PPP.

6. The contractor shall comply with OPSEC content review policies within the Agency. A content review is an evaluation of all information, to include all CUI, intended for release outside the control of the organization or release to the public. OPSEC focuses on identifying and protecting the organization s unclassified information that may individually or in the aggregate lead to the compromise of classified information and sensitive activities. The contractor will ensure that these reviews are conducted according to agency guidance in accordance with mandates from DoDD 5205.02E, DoD OPSEC Program, DoDM 5205.02-M, DoD OPSEC Program Manual, DoDI 5230.09, Clearance of DoD Information for Public Release, DoDI 5230.29, Security and Policy Review of DoD Information for Public Release, DoDI 5400.04, Provision of Information to Congress, DoDM 5400.07, DoD FOIA Program, and DoDI 8170.01, Online Information Management and Electronic Messaging.

7. Further OPSEC guidance may be obtained by the Prime contractor contacting the OPSEC PM by group e-mail:

dcsa.quantico.dcsa-hq.mbx.operations-security@mail.mil.

Ref 11l: Controlled Unclassified Information (CUI) / Receive, Store, or Generate Controlled Unclassified Information (CUI): Contractor will be provided and will abide by DoD Regulation 5400.7, DoD Freedom of Information Act Program, and DoD 5200.01-M, Information Security Program. Guidance provided under separate cover. In accordance with DoD Instruction 5200.48 (DoDI 5200.48) dated March 6, 2020, Contractors are required to ensure all personnel receive and complete Initial and Annual Refresher CUI education and training and maintain documentation of this training for audit purposes. Initial and Annual Refresher CUI security education, training and awareness on the required topics identified in Section 2002:30 of Title 32 CFR, including protection and management of CUI, to DoD personnel and contractors through the Center for Development of Security Excellence (CDSE).

-- CUI Courses and Resources Created for Industry:

The Center for Development of Security Excellence (CDSE) has developed an eLearning course titled DoD Controlled Unclassified Information (CUI) Training For Contractors (IF141.06.FY21.CTR). The course fulfills CUI training requirements for industry.

Additionally, CDSE has a CUI Toolkit available at https://www.cdse.edu/toolkits/cui/current.html. The Toolkit includes training, policy documents, resources, and an FAQ video.

-- Review the DoD CUI Registry at https://www.dodcui.mil to become familiar with CUI organizational index groupings and CUI categories. Policy documents addressing CUI oversight:

DoDI 5200.48 "Controlled Unclassified Information."

(https://www.esd.whs.mil/Portals/54/Documents/DD/issuances/dodi/520048p.PDF)32 CFR 2002 Part IV National Archives and Records Administration 32 CFR Part 2002 Controlled Unclassified Information (https://www.govinfo.gov/content/pkg/CFR-2017-title32-vol6/pdf/CFR-2017-title32-vol6-part2002.pdf)-- E.O. 13556 Vol 75, No 216. Controlled Unclassified Information (https://www.govinfo.gov/content/pkg/FR-2010-11-09/pdf/2010-28360.pdf)-- NIST Special Publication 800-171 Rev. 2 Protecting Controlled Unclassified Information in Nonfederal Systems and Organizations (https://csrc.nist.gov/publications/detail/sp/800-171/rev-2/final

Legacy information from existing documents (e.g. Technical Manuals) marked For Official Use Only or FOUO, that is used to create a new document/correspondence, shall follow the minimum marking requirements of DoDI 5200.48, Section 3, paragraph 3.4.a, and include the acronym "CUI" in the banner and footer of the document, and applying the designation indicator block to the cover or the first page of all unclassified documents and Information Systems (IS) displaying or containing CUI. Non-federal information systems storing and processing CUI shall be protected per NIST SP-800-171, or subsequent revisions. All transmissions to personal email accounts (Gmail, Yahoo, Comcast, etc.) and posting on social media websites (Facebook, Instagram, Twitter, LinkedIn, etc.) are prohibited. Destroy all CUI associated with this contract by any of the following approved methods: A cross-cut shredder; a certified commercial destruction vendor; a central destruction facility; incineration; chemical decomposition; pulverizing, disintegration; or methods approved for classified destruction.

Ref 11m Contractor is authorized access to and an email account to the SECRET Internet Protocol Router Network (SIRPNet) at US Government facilities only. Contractor access to SIPRNet is restricted to sites directly related to meeting the requirements of this contract as validated by the Contracting Officer (KO)/Contracting Officer Representative (COR) and the Scope of Work. The contractor will not access INTELLINK-S, while on SIPRNet without formal access authorization of the COR. If subcontracting is permitted, the contractor *may* be authorized to subcontract access to SIPRNet at US Government facilities to subcontractors *Only* with an approved subcontracting plan and Government Contracting Officer written approval. Contractor shall not access, download, or further disseminate any information or data that falls outside the scope of execution of the defined contract requirements.

IT-II Access Required. All personnel are required to possess/maintain a minimum IT-II Designation level.

Ref 10k: Contractor is authorized access to and an email account to Non-Secure Internet Protocol (IP) Router Network (NIPRNet) and the SECRET Internet Protocol Router Network (SIRPNet) at US Government facilities only. Contractor access to SIPRNet is restricted to sites directly related to meeting the requirements of this contract as validated by the Contracting Officer (KO)/Contracting Officer Representative (COR) and the Scope of Work. The contractor will not access INTELLINK-S, while on SIPRNet without formal access authorization of the

CLASSIFICATION (When filled in): UNCLASSIFIED

COR. If subcontracting is permitted, the contractor *may* be authorized to subcontract access to SIPRNet at US Government facilities to subcontractors *Only* with an approved subcontracting plan and Government Contracting Officer written approval. Contractor shall not access, download, or further disseminate any information or data that falls outside the scope of execution of the defined contract requirements.

NATO brief prior to being authorized access to SIPR is the SECNAVINST 5510.36B.

Other Comments:

Ref 10k Other:

NATO brief prior to being authorized access to SIPR

Ref 11M IT-II Access Required

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

NAME & TITLE OF REVIEWING OFFICIAL SIGNATURE

Security Manager Terrance McGowan

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.)

No Yes

OPSEC Requirements: The Operations Security (OPSEC) program and command policy, CNICINST 3070.2, dated 14 June 2021, requires that all support contractors requiring access to CNIC's sensitive but unclassified information on the CNIC critical information list (CIL) be educated on safeguarding that information. OPSEC training is required at on-boarding and annually in accordance with CNICINST 3070.2.

An OPSEC Plan protects critical information (CI) by analyzing the threat and establishing countermeasures to mitigate or prevent the collection of CI. If an OPSEC Plan is determined to be required in this contract, the Contracting Officer Representative (COR) will provide the CNIC CIL and OPSEC Plan template to the contractor promptly after the award of the contract. The contractor shall thereupon provide a complete OPSEC Plan within thirty (30) days of receipt of the CNIC CIL and template.

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.)

No Yes

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

a. GCA NAME

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

NAVSUP FLC Norfolk, Philadelphia

N00189

c. ADDRESS (Include ZIP Code) 700 Robbins Ave. Bldg 2B Philadelphia, PA 19111

d. POC NAME

e. POC TELEPHONE (Include Area Code)

f. EMAIL ADDRESS (See Instructions)

Michael Capilato

(771) 229-0619 michael.v.capilato.civ@us.navy.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

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)

N00189

h. SIGNATURE

i. DATE SIGNED (See Instructions)

CLASSIFICATION (When filled in): UNCLASSIFIED

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.)