J-11 DD254 for N00024-26-R-4114 - Signed.pdf

CLASSIFICATION (When filled in): Unclassified N00024-26-R-4114

PREVIOUS EDITION IS OBSOLETE. Page 1 of 6DD 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:

June 30, 2025

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

Secret

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

a. PRIME CONTRACT NUMBER (See instructions.)

b. SUBCONTRACT NUMBER

c. SOLICITATION OR OTHER NUMBER

N00024-26-R-4114

DUE DATE (YYYYMMDD)

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

a. ORIGINAL (Complete date in all cases.)

DATE (YYYYMMDD)

20240916

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.N00024-21-D-4114

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

TBD

b. CAGE CODE

TBD

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

TBD

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.)

Mid-Atlantic Regional Maintenance Center

(MARMC)

9727 Avionics Loop Norfolk VA 23511-21245299

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

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

MARMC

9727 Avionics Loop Norfolk VA 23511 (0): 757-400-0357

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

Puget Sound Naval Shipyard and Intermediate Maintenance Facility (PSNS-IMF) Code 1120 1400 Farragut Avenue Stop 2014 Bremerton WA 98314-2014

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

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

PSNS-IMF

1400 Farragut Avenue Stop 2014 Bremerton WA 98314-2014 (O): 360-476-3238

PREVIOUS EDITION IS OBSOLETE. Page 2 of 6DD FORM 254, APR 2018

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

Southwest Regional Maintenance Center

(SWRMC)

3755 Brinser Street Ste 1 San Diego CA 92136-5299

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

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

SWRMC

3755 Brinser Street Ste 1 San Diego CA 92136-5299 (O): 619-556-5537

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

Joint Base Pearl Harbor - Hickam

(JBPHH)

850 Ticonderoga Street Pearl Harbor HI 96860 - 5101

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

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

JBPHH

850 Ticonderoga Street Pearl Harbor HI 96860- 5101 (O): 808-449-1001

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

Norfolk Naval Shipyard

(NNSY)

Security and Fire Office Code 1120 Portsmouth VA 23709-5000

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

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

NNSY

Security and Fire Office Code 1120 Portsmouth VA 23709-5000 (O): 757-396-5131

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

Pearl Harbor Naval Shipyard and IMF

(PHNSY-IMF)

667 Safeguard Street Ste 100 Pearl Harbor HI 96860-5033

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

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

PHNSY-IMF

667 Safeguard Street Ste 100 Pearl Harbor HI 96860-5033 (O): 808-473-800 x3339

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

Naval Ship Repair Facility and Japan Regional Maintenance Center (SRF-JRMC) Yokosuka Honcho Yokosuka Bldg 2046 Kanagawa 238-0041 Japan

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

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

SRF-JRMC Yokosuka Honcho Yokosuka Bldg 2046 Kanagawa 238-0041 Japan (O): 0 l l-81-46-816-5488

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

Naval Ship Repair Facility and Japan Regional Maintenance Center (SRF-JRMC) Sasebo Hirasemachi Sasebo Nagasaki 857-0056 Japan

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

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

SRF-JRMC Sasebo Hirasemachi Sasebo Nagasaki 857-0056 Japan (O): 0l l-81-956-50-1110

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

Naval Station Everett 2000 West Marine View Drive Everett WA 98207

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

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

Naval Station Everett 2000 West Marine View Drive Everett WA 98207 (O): 425-304-3260

9. GENERAL UNCLASSIFIED DESCRIPTION OF THIS PROCUREMENT

New award for Carrier Engineering Maintenance Assist Team (CEMAT) / Surface Engineering Maintenance Assist Team (SEMAT) in support of maintenance and planning for the overhaul and repair of equipment and systems associated with U.S. Navy Aircraft Carriers (CVN) and U.S. Navy Surface Ships.

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

PREVIOUS EDITION IS OBSOLETE. Page 3 of 6DD FORM 254, APR 2018

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.)

"NNPI - NUCLEAR WORK AREA"

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 DoDI 5200.48, 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)

Commander, Naval Sea Systems Command (SEA 00D)

Public Release Authority:

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.)

This DD254 is for solicitation purposes only; therefore, it must be returned to SEA 00P3 to be updated upon contract award before the contract DD254 can be issued to the contractor.

No security classification guides currently exist for this contract. Classified information generated in support of this contract must be marked in accordance with the source material provided by the program office.

Item: l0(b) & (k) 1. (U) Security Controls on the Dissemination or NNPI Received or Generated Under NAVSEA Contracts 12/1/2011.

Item: l0(b) & (k) 2. (U) OPNAVINST, N9210.3 Safeguarding of Naval Nuclear Propulsion Information (NNPI) 6/7/2010.

Item: l0(b) 3. (C-RD) CG-RN-1, REV.3, CHANGES 1-24, DOE-DOD SCG for the NNPI which includes Interpretive Guidance Bulletins 1-19 and successor.

Item: l0(b) 4. Access to NNPI RD for this contract requires a final U.S. Government National Security Clearance at the appropriate level

PREVIOUS EDITION IS OBSOLETE. Page 4 of 6DD FORM 254, APR 2018 and an NNPI RD security briefing from the Facility Security Officer (FSO).

Item: l0(b) & (k) 5. Processing of NNPI on non-federal IT systems requires NAVSEA 08 authorization per OPNAVINST N9210.3, using the procedures identified in NAVSEA ltr 08B/19-03823, dated 2 August 2019.

Item: 10(b) & (k) 6. The contractor must maintain a current Certification of eligibility from the Defense Logistics Agency, Joint Certification Office for access to export-controlled Controlled Unclassified Information (CUI), which includes U-NNPI. DD Form 2345, Militarily Critical Technical Data Agreement, applies.

Item: 10(b) & (k) 7. The contractor must provide a copy of subcontractor DD254s issued under this contract, where RD/NNPI is shared to NAVSEA 08 Security, via the NAVSEA 00P3 Industrial Security Mailbox: usn.ncr.comnavseasyscomdc.mbx.SEA00P-Industrial- Security@us.navy.mil.

Item: 10(b) RD & (d) FRD. Contractor will receive and come into contact with Restricted Data (RD), and Formerly Restricted Data (FRD) on classified capabilities, operational and technical performance specifications, parameters and test data. RD/FRD information will be handled and controlled in accordance with the requirements of the NISPOM 32 CFR Part 117. Contractor is permitted access to RD/FRD in performance of the contract.

Item: 10(b) & (d) Continued: RD/FRD access requires a final U.S. Government clearance at the appropriate security level prior to access to RD/FRD. The highest level of classification is SECRET, with access requirements to program related information. Program related accesses, however, will require Contractor employees to have a current T5. FRD access is handled in the same manner as NSI.

Item: l0(j). All Controlled Unclassified Information (CUI) associated with this contract must be protected per the guidance provided for Item 11(1) of this DD Form 254.

Item: l l(b). Classified information will be safeguarded in accordance with the classification guidance identified in the source material.

Item: 11(j). The Contractor shall utilize the NAVSEA Critical Information and Indicators List, Ser COS/492 of Nov 29, 2023 to help identify and protect critical information associated with this contract.

Item: l l(j). Continued: During the period of this contract, the Contractor may be exposed to, use, or produce, NAVSEA Critical Information (CI) and/or observables and indicators which may lead to discovery of CI. NAVSEA's CI will not be distributed to unauthorized third parties, including foreign governments, or companies under Foreign Ownership, Control, or Influence (FOCI).

Item: l l(j). Continued: Assembled large components/systems being transported to and from testing areas, other production or government facilities (whether or not on public roadways) shall be in an enclosed van trailer or covered flatbed trailer. Component/System outside storage, staging, and test areas shall be shielded/obscured from public view wherever physically possible.

Item: l l(j). Continued: NAVSEA's CI shall not be publicized in corporate wide newsletters, trade magazines, displays, intranet pages or public facing websites. Media requests related to this project shall be directed to NAVSEA Public Release Authority listed in Item 12 of this DD Form 254.

Item: 11(j). Continued: Any attempt by unauthorized third parties to solicit, obtain, photograph, or record, or; incidents of loss/compromise of government Classified or CI, Business Sensitive and Company Proprietary information related to this contract or other programs must be immediately reported to the Facility Security Officer, DCSA and/or the Naval Criminal Investigative Service, and SEA 00P6. Questions concerning these requirements shall be directed to SEA 00P6.

Item: 11(j). Continued: Performance under this contract requires the contractor to adhere to OPSEC requirements. OPSEC requirements are additional to the requirements of the NISPOM, 32 CFR Part 117, therefore, the Contractor may not impose OPSEC requirements on its subcontractors unless NAVSEA approves the OPSEC requirements.

Item: 11(1). Legacy information from existing docmnents (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. Nonfederal information systems storing and processing CUI shall be protected per NIST SP-800-171, or subsequent revisions. All transmissions to personal email accounts (AOL, Yahoo, Hotmail, 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 c01runercial destruction vendor; a central destruction facility; incineration; chemical decomposition; pulverizing, disintegration; or methods approved for classified destruction.

Item: 11(1). U-NNPI CUI must be protected in accordance with OPNAVINST N9210.3 and may not be stored or processed on Non-federal

PREVIOUS EDITION IS OBSOLETE. Page 5 of 6DD FORM 254, APR 2018

AIS without written authorization of NA VSEA 08, Naval Reactors.

Classified or unclassified technical papers to be presented at a classified symposium must be approved by the NAVSEA HQ Contracting Officer's Representative (COR) in concert with SEA 00P3 and PEO Carriers, PMS312 prior to the presentation.

The Contractor must submit a request for sharing of classified and other sensitive information between prime contracts in writing to:

usn.ncr.comnavseasyscomdc.mbx.SEA00P-Industrial-Security@us.navy.mil. Each request must reference contract number N00024-26- R-4114 to identify the specific information for which approval is being sought, a justification for needing to share the information, the name of other contractor and its contract number under which the requested information will be shared.

Personnel designated as derivative classifiers shall receive derivative classification training prior to access from the contractor's Facility Security Officer (FSO). The FSO shall ensure personnel receive initial and annual refresher training during the life of this contract.

Evidence of completion, training certificates or equivalent, shall be provided to the Information System Security Manager (ISSM) no later than the individual's due date.

All classified documents must be destroyed using a National Security Agency (NSA) approved high security crosscut shredder listed on the NSA/CSS evaluated products list (EPL) for high security crosscut paper shredders, or other approved method for destroying classified information.

Copies of preliminary inquiry or investigative reports of security incidents involving classified information shall be scanned and forwarded to the Industrial Security mailbox: usn.ncr.comnavseasyscomdc.mbx.SEA00P-Industrial-Security@us.navy.mil.

The contractor must scan and forward the subcontractor’s DD 254s issued under this contract to:

usn.ncr.comnavseasyscomdc.mbx.SEA00P-Industrial-Security@us.navy.mil

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

Supply chain risk provisions are not applicable to this contract.

NAME & TITLE OF REVIEWING OFFICIAL

Kerry D. Moore (00P5) Deputy Technology Protection

SIGNATURE

Operation Security (OPSEC) requirements for this contract is reflected in item 13 of the DD Form 254 under item: 11(j).

NAME & TITLE OF REVIEWING OFFICIAL

Anthony Robinson (00P6) INFOSEC/OPSEC Division Head

SIGNATURE

Items 10(b)(k): Access to NNPI (UNNPI, NNPI NSI and NNPI RD) is authorized for this contract. Processing of NNPI on IT systems requires authorization of SEA08.

NAME & TITLE OF REVIEWING OFFICIAL

Denise Holder (08)

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.)

Item: l0(b)RD &/or l0(k) NNPI: Access to NNPI is required for this contract; (U) OPNAVINST, N9210.3 Safeguarding of Naval Nuclear Propulsion Information (NNPI) 6/7/2010 applies.

OPSEC requirements are imposed on this task. Refer to Item: 13 of this DD Form 254 for applicable guidance. These OPSEC requirements cannot be imposed on subcontractors without written consent from the NAVSEA OPSEC Program Manager. These Requirements shall not be imposed at an additional cost to the government

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.)

Item: l0(b)RD &/or l0(k) NNPI: NAVSEA 08 maintains authority to inspect for protection of NNPI (Unclassified, NSI and RD)

MOORE.KERRY.

DUAN.1043374814

Digitally signed by

MOORE.KERRY.DUAN.104337

Date: 2024.09.16 11:45:02 -04'00'

ROBINSON.ANTHON

Y.HOWARD.12669522

Digitally signed by

ROBINSON.ANTHONY.HOWA

RD.1266952216

Date: 2024.09.16 10:57:18 -04'00'

HOLDER.DENI

SE.1105017320

Digitally signed by

HOLDER.DENISE.1105017320

Date: 2024.09.24 13:31:59 -04'00'

PREVIOUS EDITION IS OBSOLETE. Page 6 of 6DD FORM 254, APR 2018

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

a. GCA NAME

PEO Carriers/ PMS 312

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

N00024

c. ADDRESS (Include ZIP Code)

1333 Isaac Hull Avenue SE Washington Navy Yard, DC 20376

d. POC NAME

Johnathan Walker

e. POC TELEPHONE (Include Area Code)

+1 (202) 781-4175

f. EMAIL ADDRESS (See Instructions) johnathan.c.walker.mil@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)

Glasgow, Shelia Y.

b. TITLE

Security Contracting Official

c. ADDRESS (Include ZIP Code)

Naval Sea Systems Command 1333 Isaac Hull Avenue SE Stop 9917 Washington Navy Yard, DC 20376

d. AAC OF THE CONTRACTING OFFICE (See Instructions)

N00024

e. CAGE CODE OF THE PRIME CONTRACTOR (See Instructions.)

f. TELEPHONE (Include Area Code)

+1 (202) 781-3548

g. EMAIL ADDRESS (See Instructions) shelia.y.glasgow.civ@us.navy.mil

h. SIGNATURE

i. DATE SIGNED (See Instructions)

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.)

SEA 08

GLASGOW

.SHELIA.Y

VONNE.12

29342793

Digitally signed by

GLASGOW.SH

ELIA.YVONNE

.1229342793 Date: 2024.09.24 15:11:42 -04'00'