Atch_26_-_Non-Disclosure_Agreement.doc

FA4800-16-R-0004

ATTACHMENT 26

SOURCE SELECTION NON-DISCLOSURE AGREEMENT

Name:______________________________ Grade:______________________

Job Title____________________________ Organization_________________

Source Selction:___________________________________________________

(or title of position, if used as an Annual Certificate IAW AFFARS 5303.104-4) Date:_______________

Briefing Acknowledgment

1. I acknowledge I have been assigned to the source selection (or position) indicated above. I am aware that unauthorized disclosure of source selection or proprietary information could damage the integrity of this procurement and that the transmission or revelation of such information to unauthorized persons could subject me to prosecution under the Procurement Integrity Laws or under other applicable laws.

2. I do solemnly swear or affirm that I will not divulge, publish, or reveal by word, conduct, or any other means, such information or knowledge, except as necessary to do so in the performance of my official duties related to this source selection and in accordance with the laws of the United States, unless specifically authorized in writing in each and every case by a duly authorized representative of the United States Government. I take this obligation freely, without any mental reservation or purpose of evasion and in the absence of duress.

3. I acknowledge that the information I receive will be given only to persons specifically granted access to the source selection information and may not be further divulged without specific prior written approval from an authorized individual.

4. If, at any time during the source selection process, my participation might result in a real, apparent, possible, or potential conflict of interest, I will immediately report the circumstances to the Source Selection Authority.

5. All personnel are requested to check the applicable block:

___ I have submitted a current OGE Form 450, Executive Branch Confidential Financial Disclosure Report, as required by DODD 5500.07, Standards of Conduct.

___ I am not required to submit an OGE Form 450.

___ I have submitted a current SF278, Executive Branch Confidential Financial Disclosure Report, s required by DODD 5500.07, Standards of Conduct

___ I am not required to submit a Form SF278

OR

___ I am a non-government employee. I have signed a proprietary information non-disclosure agreement that has been included in the contract between my firm and the government that precludes me from divulging any proprietary data to which I may gain access during the evaluation of proposal.

Neither I, nor anyone in my immediate family, have any financial interest in any company involved in this acquisition as either a prime contractor or as a subcontractor.

SIGNATURE:___________________________

DATE:

DEBRIEFING CERTIFICATE

I have been debriefed orally by _________________________as to my obligation to protect all information to which I have had access during this source selection. I no longer have any material pertinent to this source selection in my possession except material that I have been authorized in writing to retain by the SSA. I will not discuss, communicate, transmit, or release any information orally, in writing, or by any other means to anyone after this date unless specifically authorized to do so by a duly authorized representative of the United States Government.

SIGNATURE: ___________________________

DATE:________________