18-00003_DD254.pdf

CLASSIFICATION (When filled in): Unclassified

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AEM LiveCycle Designer DD FORM 254, APR 2018 PREVIOUS EDITION IS OBSOLETE. Page 1 of 4

AEM LiveCycle Designer

DD FORM 254, APR 2018

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:

October 31, 2020

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)

Confidential

b. LEVEL OF SAFEGUARDING FOR CLASSIFIED INFORMATION/

MATERIAL REQUIRED AT CONTRACTOR FACILITY

Confidential

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

a. PRIME CONTRACT NUMBER (See instructions.)

b. SUBCONTRACT NUMBER

c. SOLICITATION OR OTHER NUMBER

FD2060-18-00003

DUE DATE (YYYYMMDD)

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

a. ORIGINAL (Complete date in all cases.)

DATE (YYYYMMDD)

20180801

b. REVISED (Supersedes all previous specifications.)

REVISION 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 material received or generated under (Preceding Contract Number) is transferred to this follow-on contract.FA8522-13-D-0010

5. IS THIS A FINAL DD FORM 254? No Yes If yes, complete the following:

In response to the contractor's request dated , retention of the classified material is authorized for the period of:

6. CONTRACTOR (Include Commercial and Government Entity (CAGE) Code)

a. NAME, ADDRESS, AND ZIP CODE General Microwave Corporation

227A MICHAEL DR

SYOSSET NY 11791-5306

b. CAGE CODE

11332

c. COGNIZANT SECURITY OFFICE(S) (CSO) (Name, Address, ZIP Code, Telephone required; Email Address optional) Defense Security Service (IOFNN) 1600 Stewart Avenue, Ste. 205 Westbury, NY 11590

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) Add Row Remove last Row Delete All Rows

a. NAME, ADDRESS, AND ZIP CODE N/A

b. CAGE CODE

N/A

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

8. ACTUAL PERFORMANCE (Click button to add more locations.) Add Row Remove last Row Delete All Rows

a. LOCATION(S) (For actual performance, see instructions.)

See Block 13

b. CAGE CODE

(If applicable, see Instructions.)

N/A

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

9. GENERAL UNCLASSIFIED DESCRIPTION OF THIS PROCUREMENT

AN/ALQ-131 (V) ECM SYSTEM AND ASSOCIATED SERVICES, DATA, MATERIAL AND SUPPORT EQUIPMENT

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DD FORM 254, APR 2018

10. CONTRACTOR WILL REQUIRE ACCESS TO: (X all that apply. Provide details in Blocks 13 or 14 as set forth in the instructions.)

a. COMMUNICATIONS SECURITY (COMSEC) INFORMATION f. SPECIAL ACCESS PROGRAM (SAP) INFORMATION

b. RESTRICTED DATA g. NORTH ATLANTIC TREATY ORGANIZATION

(NATO) INFORMATION

c. CRITICAL NUCLEAR WEAPON DESIGN INFORMATION (CNWDI) (If CNWDI applies, RESTRICTED DATA must also be marked.) h. FOREIGN GOVERMENT INFORMATION

d. FORMERLY RESTRICTED DATA i. ALTERNATIVE COMPENSATORY CONTROL MEASURES

(ACCM) INFORMATION

e. NATIONAL INTELLIGENCE INFORMATION:

(1) Sensitive Compartmented Information (SCI)

(2) Non-SCI

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

k. OTHER (Specify) (See instructions.)

11. IN PERFORMING THIS CONTRACT, THE CONTRACTOR WILL: (X all that apply. See instructions. Provide details in Blocks 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 DoDM 5200.01, Volume 4 only for specific CUI protection requirements. Non-DoD Components: see instructions.)

m. OTHER (Specify) (See instructions.)

12. PUBLIC RELEASE

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)

See Block 13

Public Release Authority:

See Block 13

13. SECURITY GUIDANCE Add Signature Remove last Signature Delete All Signatures

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.)

Ref. 8.a and 11.c:Contract performance will occur at the contractors facility listed in block 6.a. The following security classification guide applies to this effort: AN/ALQ-131(V) Block II Security Classification Guide, dated 1 August 2011.

Ref. 10.j.: FOUO information provided under this contract shall be safeguarded as specified in DoDM 5200.01-V4, DoD Information Security Program: Controlled Unclassified Information.

Ref 11j: The contractor will be provided critical information under separate cover, if applicable

Ref. 12: Information requiring AF or DoD-level review will be forwarded by the *entry-level public affairs office through the MAJCOM/ DRU Public Affairs Office to the Secretary of the Air Force, Office of Public Affairs, Security and Review Division (SAF/PAX), 1690 Air Force Pentagon, Washington DC 20330-1690. *78 ABW/PA, 125 MLK, Jr Blvd, Robins AFB GA 31098.

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DD FORM 254, APR 2018

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

Add Attachment View Selected Attachment Remove Selected Attachment

NAME & TITLE OF REVIEWING OFFICIAL

Jonathan Hill Logistics Manager

SIGNATURE

NAME & TITLE OF REVIEWING OFFICIAL

John Cook Security Specialist

SIGNATURE

NAME & TITLE OF REVIEWING OFFICIAL

Melvese Harris Industrial Security Specialist

SIGNATURE

14. ADDITIONAL SECURITY REQUIREMENTS

Requirements, in addition to NISPOM requirements for classified information, are established for this contract.

No Yes 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.)

15. INSPECTIONS

Elements of this contract are outside the inspection responsibility of the CSO.

No Yes 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.)

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

a. GCA NAME

Air Force Supply Chain (AFSC) PZABB

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

FA8522

c. ADDRESS (Include ZIP Code) 235 Byron St, St 19-A Robins AFB, GA 31098

d. POC NAME

Erin Perdue

e. POC TELEPHONE (Include Area Code)

+1 (478) 926-7474

f. EMAIL ADDRESS (See Instructions) erin.perdue@us.af.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)

Erin Perdue

b. TITLE

Contracting Officer

c. ADDRESS (Include ZIP Code) 235 Byron St, St 19-A Robins AFB, GA 31098

d. AAC OF THE CONTRACTING OFFICE (See Instructions)

FA8522

e. CAGE CODE OF THE PRIME CONTRACTOR

(See Instructions.)

11332

f. TELEPHONE (Include Area Code)

+1 (478) 926-7474

g. EMAIL ADDRESS (See Instructions) erin.perdue@us.af.mil

h. SIGNATURE

i. DATE SIGNED (See Instructions)

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AEM LiveCycle Designer

DD FORM 254, APR 2018

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.)

78 ABW/IPD 638 SCMS/OMOS

DRAFT

SAMPLE

PREVIOUS EDITION IS OBSOLETE.

Page of AEM LiveCycle Designer

DD FORM 254, APR 2018

NEEDS DD67

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:

October 31, 2020 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

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

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

a. ORIGINAL (Complete date in all cases.)

b. REVISED (Supersedes all previous specifications.)

4. IS THIS A FOLLOW-ON CONTRACT?

If yes, complete the following:

Classified material received or generated under

5. IS THIS A FINAL DD FORM 254?

If yes, complete the following:

6. CONTRACTOR (Include Commercial and Government Entity (CAGE) Code)

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)

8. ACTUAL PERFORMANCE (Click button to add more locations.)

10. CONTRACTOR WILL REQUIRE ACCESS TO: (X all that apply. Provide details in Blocks 13 or 14 as set forth in the instructions.)

e. NATIONAL INTELLIGENCE INFORMATION:

11. IN PERFORMING THIS CONTRACT, THE CONTRACTOR WILL: (X all that apply. See instructions. Provide details in Blocks 13 or 14 as set forth in the instructions.)

12. PUBLIC RELEASE

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)

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.)

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.)

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.)

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

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.

18. REQUIRED DISTRIBUTION BY THE CERTIFYING OFFICIAL

9.0.0.2.20120627.2.874785 DD 254, DoD Contract Security Classification Specification List of Attachments (All Files Must be Attached Prior to Signing, i.e., for any digital signature on the form)

227A MICHAEL DR

SYOSSET NY 11791-5306

1600 Stewart Avenue, Ste. 205 Westbury, NY 11590

applies to this effort: AN/ALQ-131(V) Block II Security Classification Guide, dated 1 August 2011.

Ref. 10.j.: FOUO information provided under this contract shall be safeguarded as specified in DoDM 5200.01-V4, DoD Information Security Program: Controlled Unclassified Information.

Ref 11j: The contractor will be provided critical information under separate cover, if applicable

Ref. 12: Information requiring AF or DoD-level review will be forwarded by the *entry-level public affairs office through the MAJCOM/DRU Public Affairs Office to the Secretary of the Air Force, Office of Public Affairs, Security and Review Division (SAF/PAX), 1690 Air Force Pentagon, Washington DC 20330-1690. *78 ABW/PA, 125 MLK, Jr Blvd, Robins AFB GA 31098.

Robins AFB, GA 31098 Address: 235 Byron St, St 19-A Robins AFB, GA 31098