DD254 Draft.pdf

CLASSIFICATION (When filled in) UNCLASSIFIED

DEPARTMENT OF DEFENSE 0MB No. 0704-0567

CONTRACT SECURITY CLASSIFICATION SPECIFICATION

0MB af:froval expires:

Augus 1, 2028

(The requirements of the National Industrial Security Program (NISP) apply to all security aspects of this effort involving classified information.)

The public reporting burden for this collection of information, 0704-0567, is estimated to average 70 minutes per response, induding 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 suggesfons for reducing the burden, to the Department of Defense, Washington Headquarters Services, at whs.mc-alex.esd.mbx.dd-dod-information-<:ollections@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 wtth a collection of information if tt does not display a currenlly valid 0MB control number.

RETIJRN COMPLETED FORM AS DIRECTED IN THE INSTRUCTIONS.

1. CLEARANCE AND SAFEGUARDING

a. LEVEL OF FACILITY SECURITY CLEARANCE (FCL) REQUIRED b. LEVEL OF SAFEGUARDING FOR CLASSIFIED INFORMATION/ (See Instructions) MATERIAL REQUIRED AT CONTRACTOR FACILITY

TOP SECRET NONE

2. THIS SPECIFICATION IS FOR: ()( and complete as applicable.) 3. THIS SPECIFICATION IS: (Xandcomplete as applicable.)

■ a. PRIME CONTRACT NUMBER (See instructions.) DA TE(YYYYMMDD)

N00 18926DW003 ■ a. ORIGINAL (Complete date in all cases.)

□ b.SUBCONTRACT NUMBER

□ b. REVISED (Supersedes all previous specifications.)

REVISON NO. DA TE(YYYYMMDD)

□ c. SOLICITATION OR OTHER NUMBER DUE DA TE(YYYYMMDD) □ c. FINAL (Complete Item 5 in all cases.) DA TE(YYYYMMDD)

□ No ■ves ,,. ,

4. IS THIS A FOLLOW-ON CONTRACT? If yes, complete the following:

Classified marterial received or generated under N00 1892 lDG00 1 (Preceding Contract Number) i.s transferred to this follow-on contract.

5. IS THIS A FINAL DD FORM 254? ■ No Oves 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) b.CAGE CODE c. COGNIZANT SECURITY OFFICE(S) (CSO)

(Name, Address ZIP Code, Telephone required; Ema,J Address optional)

M-VAB

277 BENDIX ROAD

SUITE 200

a. NAME, ADDRESS, AND ZIP CODE

VIRGINIA BEACH, VA 23452

(757) 457-3270

DSS.DSS-SOUTHERN.DSS-ISFO.MBX.VIRGINL\.-BEACH-FIELD-OFFICE@MAIL.MIL

7. SUBCONTRACTOR( S) (Click butto')Jf 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, ZJP Code, Telephone required; Email Address optional)

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

b. CAGE CODE c. COGNIZANT SECURITY OFFICE(S) (CSO) (If applicable, (Name, Address, ZJP Code, Telephone required; Email Address optional) see Instructions.)

M-VAB

277 BENDIX ROAD

SUITE 200

VIRGINIA BEACH, VA 23452

(757) 457-3270

a. LOCA TION(S) (For actual performance, see instructions)

DSS.DSS-SOUTHERN.DSS-ISFO.MBX.VIRGINL\.-BEACH-FIELD-OFFICE@MAIL.MIL

a. LOCA TION(S) (For actual performance, see instructions) b. CAGE CODE c. COGNIZANT SECURITY OFFICE(S) (CSO) (If applicable, see Instructions.) (Name, Address, ZIP Code, Telephone required; Email Address optional)

OPTEVFOR

7970 Diven Street Norfolk, VA 23505-1498 United States

9. GENERAL UNCLASSIFIED DESCRIPTION OF THIS PROCUREMENT

DD FORM 254, APR 2018 PREVIOUS EDITION IS OBSOLETE. Page 1 of 7

CLASSIFICATION (When filled in)" UNCLASSIFIED

CLASSIFICATION (When filled in) UNCLASSIFIED

Prior approval of the GCA is required before a Prime Contractor can impose additional security requirements on a subcontractor.

15. INSPECTIONS

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

If Yes, explain and identify specific areas and government actwity responsible for inspections. The field will expand as text is added or you can also use item

Yes 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

Fleet Logistics Center Norfolk VA

c. ADDRESS (Include ZIP Code)

1968 Gilbert Street, STE 600 Norfolk, VA 23505-1498

d. POC NAME

b. ACTIVITY ADDRESS CODE (AAC) OF THE

CONTRACTING OFFICE(See Instructions)

N00189

Carlton Walton

e. POC TELEPHONE (Include Area Code)

(564) 230-2997

f. EMAIL ADDRESS (See Instructions) carlton.t.walton.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 j 7h, no changes can be made as the form will be locked.

a. TYPED NAME OF CERTIFYING OFFICIAL (Last, First, Middle Initial) d. AAC OF THE CONTRACTING OFFICE h. SIGNATURE (See Instructions) (See Instructions)

Timothy Burrows N00 189

b. TITLE e. CAGE CODE OF THE PRIME CONTRACTOR

Command COR (See Instructions)

C. ADDRESS (Include ZIP Code)

OPERATIONAL TEST AND EVALUATION FORCE

7970 DIVEN STREET

NORFOLK, VA 23505-1498

18. REQUIRED DISTRIBUTION BY THE CERTIFYING OFFICIAL

■ a. CONTRACTOR

f. TELEPHONE (Include Area Code)

(757) 457-6563

g. EMAIL ADDRESS (See Instructions) timothy.r.burrows.civ@us.navy.mil

□ f. OTHER AS NECESSARY

i. DA TE SIGNED

(See Instructions)

□ b.SUBCONTRACTOR

(�ore room is needed, continue in Item 13 or on additional page if necessary.)

□ c. COGNIZANT SECURITY OFFICE FOR PRIME AND

SUBCONTRACTOR

□ d. U.S. ACTIVITY RESPONSIBLE FOR OVERSEAS SECURITY

ADMINISTRATION

□ e. ADMINISTRATIVE CONTRACTING OFFICER

DD FORM 254, APR 2018 PREVIOUS EDITION IS OBSOLETE.

CLASSIFICATION (When filled in)' UNCLASSIFIED