Offutt SSO SOA Form.pdf

UNCLASSIFIED//FOR OFFICIAL USE ONLY

(U) Question 9: Do any of the member of your organization's board of directors (or similar governing body) or officers, executive personnel, general partners, regents, trustees, or senior management officials of your organization hold any positions with, or serve as consultants for any foreign interest?

(U) Ifm, Yes No

1. Provide the name, title, citizenship, immigration status and clearance, or exclusion status on all such persons.

11. Identify by name and address each foreign interest with which such persons serve and indicate the capacity in which he/she is serving.

111. Include a Statement of Full Disclosure of Foreign Affiliation for every cleared individual who is a representative of a foreign interest.

(U) Question 10: Is there any other factor that indicates or demonstrates a capability of a foreign interest to control or influence the operations or management of your organization?

Yes No

(U) If yes, describe the foreign involvement in detail including why the involvement would not be reportable in the preceding questions.

(U) By signing below, the undersigned does hereby agree that the information contained in this document is accurate and complete at the time of submission.

Signed: ________________ _

Printed Name:

Title:

Date:

UNCLASSIFIED//FOR OFFICIAL USE ONLY