N0025323Q0027 Amendment 0001 Conformed Copy.pdf

SEE ADDENDUM

(No Collect Calls)

N0025323Q0027 26-May-2023

b. TELEPHONE NUMBER

360-315-6798

8. OFFER DUE DATE/LOCAL TIME

01:00 PM 06 Jun 2023

5. SOLICITATION NUMBER 6. SOLICITATION ISSUE DATE

AUTHORIZED FOR LOCAL REPRODUCTION

PREVIOUS EDITION IS NOT USABLE

STANDARD FORM 1449 (REV. 2/2012)

Prescribed by GSA – FAR (48 CFR) 53.212

(TYPE OR PRINT)

(SIGNATURE OF CONTRACTING OFFICER)

ADDENDA ARE

26. TOTAL AWARD AMOUNT (For Gov t. Use Only )

23.

CODE 10. THIS ACQUISITION IS

SUCH ADDRESS IN OFFER

17b. CHECK IF REMITTANCE IS DIFFERENT AND PUT

BELOW IS CHECKED

TELEPHONE NO.

N002539. ISSUED BY

18b. SUBMIT INVOICES TO ADDRESS SHOWN IN BLOCK 18a. UNLESS BLOCK

7. FOR SOLICITATION

INFORMATION CALL:

a. NAME

REBECCA JETT

2. CONTRACT NO. 3. AWARD/EFFECTIVE DATE 4. ORDER NUMBER

(TYPE OR PRINT)

30b. NAME AND TITLE OF SIGNER 30c. DATE SIGNED 31b. NAME OF CONTRACTING OFFICER

30a. SIGNATURE OF OFFEROR/CONTRACTOR 31a.UNITED STATES OF AMERICA

0 27a. SOLICITATION INCORPORATES BY REFERENCE FAR 52.212-1. 52.212-4. FAR 52.212-3. 52.212-5 ARE ATTACHED.

25. ACCOUNTING AND APPROPRIATION DATA

1. REQUISITION NUMBER

20.

ADDITIONAL SHEETS SUBJECT TO THE TERMS AND CONDITIONS SPECIFIED.

OFFEROR TO COMPLETE BLOCKS 12, 17, 23, 24, AND 30

SOLICITATION/CONTRACT/ORDER FOR COMMERCIAL ITEMS

ARE NOT ATTACHED

27b. CONTRACT/PURCHASE ORDER INCORPORATES BY REFERENCE FAR 52.212-4. FAR 52.212-5 IS ATTACHED. ADDENDA ARE ARE NOT ATTACHED

(BLOCK 5), INCLUDING ANY ADDITIONS OR CHANGES WHICH ARE

SET FORTH HEREIN, IS ACCEPTED AS TO ITEMS:

. YOUR OFFER ON SOLICITATION

28. CONTRACTOR IS REQUIRED TO SIGN THIS DOCUMENT AND RETURN

% FOR:SET ASIDE:UNRESTRICTED OR X

SMALL BUSINESSX

17a.CONTRACTOR/ CODE FACILITY

OFFEROR CODE

NAVAL UNDERSEA WARFARE CENTER

ATTN: REBECCA JETT

REBECCA.JETT@NAVY.MIL

610 DOWELL STREET, BLDG 206

KEYPORT WA 98345

18a. PAYMENT WILL BE MADE BY CODE

RATED ORDER UNDER

DPAS (15 CFR 700)

13a. THIS CONTRACT IS AX

13b. RATING

DO-C9

CODE15. DELIVER TO CODE 16. ADMINISTERED BY

SEE SCHEDULE

12. DISCOUNT TERMS11. DELIVERY FOR FOB DESTINA-

TION UNLESS BLOCK IS

MARKED

SEE SCHEDULE

14. METHOD OF SOLICITATION

RFQ IFB RFPX

FAX:

TEL: 360-315-6798 SERVICE-DISABLED

VETERAN-OWNED

SMALL BUSINESS

8(A)

HUBZONE SMALL

BUSINESS

SIZE STANDARD:

$41,000,000

NAICS:

221310

X

OFFER DATED

29. AWARD OF CONTRACT: REF.

DELIVER ALL ITEMS SET FORTH OR OTHERWISE IDENTIFIED ABOVE AND ON ANY

COPIES TO ISSUING OFFICE. CONTRACTOR AGREES TO FURNISH AND

EMAIL:

TEL:

31c. DATE SIGNED

SEE SCHEDULE

SCHEDULE OF SUPPLIES/ SERVICESITEM NO. QUANTITY UNIT UNIT PRICE AMOUNT

24.22.21.19.

WOMEN-OWNED SMALL BUSINESS (WOSB)

ELIGIBLE UNDER THE WOMEN-OWNED

SMALL BUSINESS PROGRAM

EDWOSB

32g. E-MAIL OF AUTHORIZED GOVERNMENT REPRESENTATIVE

SOLICITATION/CONTRACT/ORDER FOR COMMERCIAL ITEMS

(CONTINUED)

PAGE 2 OF65

ACCEPTED, AND CONFORMS TO THE CONTRACT, EXCEPT AS NOTED: ______________________________________________________

32a. QUANTITY IN COLUMN 21 HAS BEEN

RECEIVED INSPECTED

32b. SIGNATURE OF AUTHORIZED GOVERNMENT

REPRESENTATIVE

32c. DATE 32d. PRINTED NAME AND TITLE OF AUTHORIZED GOVERNMENT

REPRESENTATIVE

32e. MAILING ADDRESS OF AUTHORIZED GOVERNMENT REPRESENTATIVE 32f . TELEPHONE NUMBER OF AUTHORIZED GOVERNMENT REPRESENTATIVE

37. CHECK NUMBER

FINALPARTIALCOMPLETE

36. PAYMENT35. AMOUNT VERIFIED

CORRECT FOR

34. VOUCHER NUMBER

FINAL

33. SHIP NUMBER

PARTIAL

38. S/R ACCOUNT NUMBER 39. S/R VOUCHER NUMBER 40. PAID BY

41a. I CERTIFY THIS ACCOUNT IS CORRECT AND PROPER FOR PAYMENT

41b. SIGNATURE AND TITLE OF CERTIFYING OFFICER 41c. DATE

42a. RECEIVED BY (Print)

42b. RECEIVED AT (Location)

42c. DATE REC'D (YY/MM/DD) 42d. TOTAL CONTAINERS

STANDARD FORM 1449 (REV. 2/2012) BACK

Prescribed by GSA – FAR (48 CFR) 53.212

AUTHORIZED FOR LOCAL REPRODUCTION

PREVIOUS EDITION IS NOT USABLE

SEE SCHEDULE

20.

SCHEDULE OF SUPPLIES/ SERVICES

21.

QUANTITY UNIT

22. 23.

UNIT PRICE

24.

AMOUNT

19.

ITEM NO.

N0025323Q0027

Section SF 1449 - CONTINUATION SHEET

STATEMENT OF WORK

STATEMENT OF WORK

Carbon Filtration Vessels

1. Scope

1.1. Provide new carbon filtration units to be used in an aqueous system for one year plus three options.

1.2. Technical Point of Contact will be announced at time of award.

1.3. Delivery addresses are as follows:

Joint Base Pearl Harbor-Hickam (JBPH) – DoDAAC N44944 West Lock Annex, Building 440 Eva Beach, HI

NUWC Keyport (Keyport) – DoDAAC N00253 601 Dowell St.

Keyport, WA

2. Requirements

2.1. Vessel shall be Snyder Ultratainer PN 68445 or equivalent to meet the following specifications:

- Polyethylene IBC.

- Capacity: 330 gallons.

- Size: 46” wide x 46” deep x 70” high.

- UN DOT certified 15 psi (100 kPa).

- UN DOT test and inspection dates within 9 months of delivery date.

- Four way forklift access.

- Two replaceable 2 inch bungs for inlet and outlet fittings.

- 5 inch or larger center top tank opening with threaded cap and seal; cap with 2 inch center opening.

- Vessel capable of having carbon installed and removed.

- 2 inch bottom drain valve to meet material requirements below.

2.2. Internal piping shall include inlet and outlet piping as well as drain screen and shall be installed to meet the following specifications and material requirements below:

- Piping material shall be Polypropylene.

- Inlet piping at first vessel 2 inch bungs consists of 2 inches exposed length of 1.5”. MNPT connection for installation site inlet flow pipe to connect to unit.

- Outlet piping at second vessel 2 inch bung consists of horizontal leg at bottom of tank made of slotted piping (well screen type) with 0.020” slots and 2 inches exposed length of 1.5” MNPT connection for installation site outlet flow pipe to connect to unit. Slotted piping and 1.5” connection shall be connected to ensure free flow of liquid from bottom of tank to outlet without restriction.

Outlet piping shall prevent carbon from entering outlet flow. Outlet piping integrity must not be compromised by installation of carbon media or weight of carbon during use.

- Vent connection at center opening of center port cap consists of 1.5” FNPT connection for installation site vent pipe to connect to unit.

- Screen installed on bottom drain valve to allow drainage of liquid without allowing carbon to pass through the valve.

- Inlet and outlet ports shall be legibly and permanently marked.

- Piping shall be easily replaceable and capable of having carbon replaced without affecting integrity of components and seals.

- All connections shall be capped or plugged for shipping.

2.3. Materials must be compatible with seawater and Otto Fuel. Note for Otto Fuel only:

- Compatible materials: Polyethylene propylene, polyethylene, nylon, Teflon, silicone rubber, natural rubber, glass.

- Incompatible materials: Buna-N, copper, polyurethane, polyvinylchloride, synthetic rubber, Viton.

2.4. Carbon shall meet the following specifications:

- 8x30 mesh activated coconut shell carbon (new or reactivated).

- 1,000 pounds per filter vessel.

- Carbon Tetrachloride Activity (CTC): 60%.

- Apparent Density (lb/cu.ft.): 30 average.

- Total Ash Content: 8% maximum.

- Hardness (ball abrasion): 90 average.

- Iodine number: 800 minimum.

3. Testing

3.1. Leakage testing shall be performed upon completion of each vessel assembly as described in Section 2.

The test shall include 15 psi air applied internal to the vessel for 30 minutes without leaking.

3.2. A written test procedure shall be submitted to the technical Point of Contact (POC) for approval within 21 days of award. (See CDRL A001)

3.3. A Certificate of Compliance is required with each unit delivery in accordance with NAVSEA Clause E-

246-W002 Certificate of Compliance (OCT 2018)

4. Data and Reporting

4.1. Contractor shall submit a written test plan. (See CDRL A001)

4.2. Contractor shall submit test reports with each delivered unit. (See CDRL A002)

ITEM NO SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT

0001 2 Each Carbon Filtration Units - NUWC Keyport

FFP

Manufactured in accordance with (IAW) the Statement of Work (SOW) and delivered to NUWC Division Keyport.

Certificate of Compliance is required with each delivery of units.

Please indicate if the material you are quoting is ___ Brand Name, or ___ Equal

If quoting Equal material, you must provide:

• Manufacturer: ____________________

• Part Number: ____________________

• Specification Sheet MUST be attached with your quote.

If any portion of the offered end product(s) is/are manufactured outside the United States, offerors must provide the actual manufacturer(s)/ Service Provider(s) information [If more than one, identify all]:

Actual Manufacturer/ Service Provider:

Manufactured Item(s) Country of Origin:

FOB: Destination

PSC CD: 4610

NET AMT

0002 1 Each Carbon Filtration Units - JBPH

FFP

Manufactured in accordance with (IAW) the Statement of Work (SOW) and delivered to Joint Based Pearl Harbor (JBPH).

Certificate of Compliance is required with each delivery of units.

Please indicate if the material you are quoting is ___ Brand Name, or ___ Equal

If quoting Equal material, you must provide:

• Manufacturer: ____________________

If any portion of the offered end product(s) is/are manufactured outside the United States, offerors must provide the actual manufacturer(s)/ Service Provider(s) information [If more than one, identify all]:

Actual Manufacturer/ Service Provider:

Manufactured Item(s) Country of Origin:

0003 1 Each CDRL A001 - Test Procedure

FFP

Data in accordance with Exhibit A, Data Items A001: Contract Data Requirements Lists, DD Form 1423-1 (Not Separately Priced).

0004 1 Each CDRL A002 - Test Inspection Report

FFP

Data in accordance with Exhibit A, Data Items A002:Contract Data Requirements Lists, DD Form 1423-1 (Not Separately Priced).

Carbon Filtration Units - NUWC Keyport

FFP

Option YR 1 *** Information Only CLIN, please see priced SubCLINS 1001AA through

1001AB ***

Certificate of Compliance is required with each delivery of units.

Please indicate if the material you are quoting is ___ Brand Name, or ___ Equal

If quoting Equal material, you must provide:

• Manufacturer: ____________________

Manufactured in accordance with (IAW) the Statement of Work (SOW) and delivered to NUWC Division Keyport.

1001AA 2 Each OPTION Carbon Filtration Units - NUWC Keyport

FFP

Option YR 1

This is an Option Item only and in no way are purchased or guaranteed under the resulting contract. Work cannot be started or performed under the Option Items without Option Exercise by the Contracting Officer in accordance with FAR Clause 52.217-7 VAR I.

1001AB 1 Each OPTION Carbon Filtration Units - NUWC Keyport

FFP

Option YR 1

This is an Option Item only and in no way are purchased or guaranteed under the resulting contract. Work cannot be started or performed under the Option Items without Option Exercise by the Contracting Officer in accordance with FAR Clause 52.217-7 VAR I.

OPTION Carbon Filtration Units - JBPH

FFP

Option YR 1 *** Information Only CLIN, please see priced SubCLINS 1002AA through

1002AB ***

Certificate of Compliance is required with each delivery of units.

Please indicate if the material you are quoting is ___ Brand Name, or ___ Equal

If quoting Equal material, you must provide:

• Manufacturer: ____________________ delivered to Joint Based Pearl Harbor (JBPH).

1002AA 1 Each OPTION Carbon Filtration Units - JBPH

FFP

Option YR 1

This is an Option Item only and in no way are purchased or guaranteed under the resulting contract. Work cannot be started or performed under the Option Items without Option Exercise by the Contracting Officer in accordance with FAR Clause 52.217-7 VAR I.

1002AB 2 Each OPTION Carbon Filtration Units - JBPH

FFP

Option YR 1

This is an Option Item only and in no way are purchased or guaranteed under the resulting contract. Work cannot be started or performed under the Option Items without Option Exercise by the Contracting Officer in accordance with FAR Clause 52.217-7 VAR I.

1003 1 Each OPTION CDRL A002 - Test Inspection Report

FFP

Data in accordance with Exhibit A, Data Items A002:Contract Data Requirements Lists, DD Form 1423-1 (Not Separately Priced).

OPTION Carbon Filtration Units - NUWC Keyport

FFP

Option YR 2 *** Information Only CLIN, please see priced SubCLINS 2001AA through

2001AB ***

Certificate of Compliance is required with each delivery of units.

Please indicate if the material you are quoting is ___ Brand Name, or ___ Equal

If quoting Equal material, you must provide:

• Manufacturer: ____________________

2001AA 1 Each OPTION Carbon Filtration Units - NUWC Keyport

FFP

Option YR 2

Manufactured in accordance with (IAW) the Statement of Work (SOW) and delivered to NUWC Division Keyport.

This is an Option Item only and in no way are purchased or guaranteed under the resulting contract. Work cannot be started or performed under the Option Items without Option Exercise by the Contracting Officer in accordance with FAR Clause 52.217-7 VAR I.

2001AB 1 Each OPTION Carbon Filtration Units - NUWC Keyport

FFP

Option YR 2

Manufactured in accordance with (IAW) the Statement of Work (SOW) and delivered to NUWC Division Keyport.

This is an Option Item only and in no way are purchased or guaranteed under the resulting contract. Work cannot be started or performed under the Option Items without Option Exercise by the Contracting Officer in accordance with FAR Clause 52.217-7 VAR I.

OPTION Carbon Filtration Units - JBPH

FFP

Option YR 2 *** Information Only CLIN, please see priced SubCLINS 2002AA through

2002AB ***

Certificate of Compliance is required with each delivery of units.

Please indicate if the material you are quoting is ___ Brand Name, or ___ Equal

If quoting Equal material, you must provide:

• Manufacturer: ____________________

2002AA 1 Each OPTION Carbon Filtration Units - JBPH

FFP

Option YR 2

Manufactured in accordance with (IAW) the Statement of Work (SOW) and delivered to Joint Based Pearl Harbor (JBPH).

This is an Option Item only and in no way are purchased or guaranteed under the resulting contract. Work cannot be started or performed under the Option Items without Option Exercise by the Contracting Officer in accordance with FAR Clause 52.217-7 VAR I.

2002AB 1 Each OPTION Carbon Filtration Units - JBPH

FFP

Option YR 2

Manufactured in accordance with (IAW) the Statement of Work (SOW) and delivered to Joint Based Pearl Harbor (JBPH).

This is an Option Item only and in no way are purchased or guaranteed under the resulting contract. Work cannot be started or performed under the Option Items without Option Exercise by the Contracting Officer in accordance with FAR Clause 52.217-7 VAR I.

2003 1 Each OPTION CDRL A002 - Test Inspection Report

FFP

Data in accordance with Exhibit A, Data Items A002:Contract Data Requirements Lists, DD Form 1423-1 (Not Separately Priced).

OPTION Carbon Filtration Units - NUWC Keyport

FFP

Option YR 3 *** Information Only CLIN, please see priced SubCLINS 3001AA through

3001AB ***

Certificate of Compliance is required with each delivery of units.

Please indicate if the material you are quoting is ___ Brand Name, or ___ Equal

If quoting Equal material, you must provide:

• Manufacturer: ____________________

3001AA 1 Each OPTION Carbon Filtration Units - NUWC Keyport

FFP

Option YR 3

Manufactured in accordance with (IAW) the Statement of Work (SOW) and delivered to NUWC Division Keyport.

This is an Option Item only and in no way are purchased or guaranteed under the resulting contract. Work cannot be started or performed under the Option Items without Option Exercise by the Contracting Officer in accordance with FAR Clause 52.217-7 VAR I.

3001AB 1 Each OPTION Carbon Filtration Units - NUWC Keyport

FFP

Option YR 3

Manufactured in accordance with (IAW) the Statement of Work (SOW) and delivered to NUWC Division Keyport.

This is an Option Item only and in no way are purchased or guaranteed under the resulting contract. Work cannot be started or performed under the Option Items without Option Exercise by the Contracting Officer in accordance with FAR Clause 52.217-7 VAR I.

OPTION Carbon Filtration Units - JBPH

FFP

Option YR 3 *** Information Only CLIN, please see priced SubCLINS 3002AA through

3002AB ***

Certificate of Compliance is required with each delivery of units.

Please indicate if the material you are quoting is ___ Brand Name, or ___ Equal

If quoting Equal material, you must provide:

• Manufacturer: ____________________

3002AA 1 Each OPTION Carbon Filtration Units - JBPH

FFP

Option YR 3

Manufactured in accordance with (IAW) the Statement of Work (SOW) and delivered to Joint Based Pearl Harbor (JBPH).

This is an Option Item only and in no way are purchased or guaranteed under the resulting contract. Work cannot be started or performed under the Option Items without Option Exercise by the Contracting Officer in accordance with FAR Clause 52.217-7 VAR I.

3002AB 1 Each OPTION Carbon Filtration Units - JBPH

FFP

Option YR 3

Manufactured in accordance with (IAW) the Statement of Work (SOW) and delivered to Joint Based Pearl Harbor (JBPH).

This is an Option Item only and in no way are purchased or guaranteed under the resulting contract. Work cannot be started or performed under the Option Items without Option Exercise by the Contracting Officer in accordance with FAR Clause 52.217-7 VAR I.

3003 1 Each OPTION CDRL A002 - Test Inspection Report

FFP

Data in accordance with Exhibit A, Data Items A002:Contract Data Requirements Lists, DD Form 1423-1 (Not Separately Priced).

INSPECTION AND ACCEPTANCE TERMS

Supplies/services will be inspected/accepted at:

CLIN INSPECT AT INSPECT BY ACCEPT AT ACCEPT BY

0001 Destination Government Destination Government 0002 Destination Government Destination Government 0003 Destination Government Destination Government 0004 Destination Government Destination Government 1001 N/A N/A N/A N/A 1001AA Destination Government Destination Government 1001AB Destination Government Destination Government 1002 N/A N/A N/A N/A 1002AA Destination Government Destination Government 1002AB Destination Government Destination Government 1003 Destination Government Destination Government 2001 N/A N/A N/A N/A 2001AA Destination Government Destination Government 2001AB Destination Government Destination Government 2002 N/A N/A N/A N/A 2002AA Destination Government Destination Government 2002AB Destination Government Destination Government

2003 Destination Government Destination Government 3001 N/A N/A N/A N/A 3001AA Destination Government Destination Government 3001AB Destination Government Destination Government 3002 N/A N/A N/A N/A 3002AA Destination Government Destination Government 3002AB Destination Government Destination Government 3003 Destination Government Destination Government

DELIVERY INFORMATION

CLIN DELIVERY DATE QUANTITY SHIP TO ADDRESS DODAAC /

CAGE

0001 14 wks. ADC 2 NAVAL UNDERSEA WARFARE CENTER

RECEIVING OFFICER

ATTN: DIVISION KEYPORT SUPPLY

OFFICER

BLDG 893

610 DOWELL STREET

KEYPORT WA 98345-7610

360 396-2760

N00253

0002 14 wks. ADC 1 NAVAL UNDERSEA WARFARE CENTER

SUBMARINE TORPEDO IMA PH

15TH STREET, BLDG. 440, WESTLOCH NB

EWA BEACH HI 96706-3381

N44944

0003 21 dys. ADC 1 NAVAL UNDERSEA WARFARE CENTER

RECEIVING OFFICER

ATTN: DIVISION KEYPORT SUPPLY

OFFICER

BLDG 893

610 DOWELL STREET

KEYPORT WA 98345-7610

360 396-2760

0004 14 wks. ADC 1 (SAME AS PREVIOUS LOCATION)

1001 N/A N/A N/A N/A

1001AA 14 wks. AOE 2 NAVAL UNDERSEA WARFARE CENTER

ATTN: DIVISION KEYPORT SUPPLY

OFFICER

BLDG 893

610 DOWELL STREET

KEYPORT WA 98345-7610

360 396-2760

1001AB 14 wks. AOE 1 (SAME AS PREVIOUS LOCATION)

1002 N/A N/A N/A N/A

1002AA 14 wks. AOE 1 NAVAL UNDERSEA WARFARE CENTER

SUBMARINE TORPEDO IMA PH

15TH STREET, BLDG. 440, WESTLOCH NB

EWA BEACH HI 96706-3381

1002AB 14 wks. AOE 2 (SAME AS PREVIOUS LOCATION)

1003 14 wks. ADC 1 NAVAL UNDERSEA WARFARE CENTER

ATTN: DIVISION KEYPORT SUPPLY

OFFICER

BLDG 893

610 DOWELL STREET

KEYPORT WA 98345-7610

360 396-2760

2001 N/A N/A N/A N/A

2001AA 14 wks. AOE 1 NAVAL UNDERSEA WARFARE CENTER

RECEIVING OFFICER

ATTN: DIVISION KEYPORT SUPPLY

OFFICER

BLDG 893

610 DOWELL STREET

KEYPORT WA 98345-7610

360 396-2760

2001AB 14 wks. AOE 1 (SAME AS PREVIOUS LOCATION)

2002 N/A N/A N/A N/A

2002AA 14 wks. AOE 1 NAVAL UNDERSEA WARFARE CENTER

SUBMARINE TORPEDO IMA PH

15TH STREET, BLDG. 440, WESTLOCH NB

EWA BEACH HI 96706-3381

2002AB 14 wks. AOE 1 (SAME AS PREVIOUS LOCATION)

2003 14 wks. ADC 1 NAVAL UNDERSEA WARFARE CENTER

ATTN: DIVISION KEYPORT SUPPLY

OFFICER

BLDG 893

610 DOWELL STREET

KEYPORT WA 98345-7610

360 396-2760

3001 N/A N/A N/A N/A

3001AA 14 wks. AOE 1 NAVAL UNDERSEA WARFARE CENTER

RECEIVING OFFICER

ATTN: DIVISION KEYPORT SUPPLY

OFFICER

BLDG 893

610 DOWELL STREET

KEYPORT WA 98345-7610

360 396-2760

3001AB 14 wks. AOE 1 (SAME AS PREVIOUS LOCATION)

3002 N/A N/A N/A N/A

3002AA 14 wks. AOE 1 NAVAL UNDERSEA WARFARE CENTER

SUBMARINE TORPEDO IMA PH

15TH STREET, BLDG. 440, WESTLOCH NB

EWA BEACH HI 96706-3381

3002AB 14 wks. AOE 1 (SAME AS PREVIOUS LOCATION)

3003 14 wks. ADC 1 NAVAL UNDERSEA WARFARE CENTER

ATTN: DIVISION KEYPORT SUPPLY

OFFICER

BLDG 893

610 DOWELL STREET

KEYPORT WA 98345-7610

360 396-2760

CLAUSES INCORPORATED BY REFERENCE

52.203-12 Limitation On Payments To Influence Certain Federal

Transactions

JUN 2020

52.204-7 System for Award Management OCT 2018 52.204-10 Reporting Executive Compensation and First-Tier

Subcontract Awards

JUN 2020

52.204-13 System for Award Management Maintenance OCT 2018 52.204-16 Commercial and Government Entity Code Reporting AUG 2020 52.204-18 Commercial and Government Entity Code Maintenance AUG 2020 52.204-19 Incorporation by Reference of Representations and

Certifications.

DEC 2014

52.204-21 Basic Safeguarding of Covered Contractor Information Systems

NOV 2021

52.209-6 Protecting the Government's Interest When Subcontracting With Contractors Debarred, Suspended, or Proposed for Debarment

NOV 2021

52.209-10 Prohibition on Contracting With Inverted Domestic Corporations

NOV 2015

52.211-6 Brand Name or Equal AUG 1999 52.211-15 Defense Priority And Allocation Requirements APR 2008 52.212-1 Instructions to Offerors--Commercial Products and

Commercial Services

NOV 2021

52.212-4 Contract Terms and Conditions--Commercial Products and Commercial Services

DEC 2022

52.217-5 Evaluation Of Options JUL 1990 52.219-6 Notice Of Total Small Business Set-Aside NOV 2020 52.219-28 Post-Award Small Business Program Rerepresentation OCT 2022 52.219-33 Nonmanufacturer Rule SEP 2021 52.222-3 Convict Labor JUN 2003 52.222-19 (Dev) Child Labor - Cooperation with Authorities and Remedies

(DEVIATION 2020-O0019)

DEC 2022

52.223-18 Encouraging Contractor Policies To Ban Text Messaging While Driving

JUN 2020

52.225-13 Restrictions on Certain Foreign Purchases FEB 2021

52.232-33 Payment by Electronic Funds Transfer--System for Award Management

OCT 2018

52.232-39 Unenforceability of Unauthorized Obligations JUN 2013 52.233-3 Protest After Award AUG 1996 52.233-4 Applicable Law for Breach of Contract Claim OCT 2004 252.203-7000 Requirements Relating to Compensation of Former DoD

Officials

SEP 2011

252.203-7002 Requirement to Inform Employees of Whistleblower Rights DEC 2022 252.203-7005 Representation Relating to Compensation of Former DoD

Officials

SEP 2022

252.204-7002 Payment For Contract Line or Subline Items Not Separately Priced

APR 2020

252.204-7003 Control Of Government Personnel Work Product APR 1992 252.204-7008 Compliance With Safeguarding Covered Defense Information

Controls

OCT 2016

252.204-7012 Safeguarding Covered Defense Information and Cyber Incident Reporting

DEC 2019

252.204-7015 Notice of Authorized Disclosure of Information for Litigation Support

MAY 2016

252.204-7017 Prohibition on the Acquisition of Covered Defense Telecommunications Equipment or Services -- Representation

MAY 2021

252.204-7018 Prohibition on the Acquisition of Covered Defense Telecommunications Equipment or Services

JAN 2021

252.204-7019 Notice of NIST SP 800-171 DoD Assessment Requirements MAR 2022 252.204-7020 NIST SP 800-171 DoD Assessment Requirements JAN 2023 252.204-7024 Notice on the Use of the Supplier Performance Risk System MAR 2023 252.211-7003 Item Unique Identification and Valuation MAR 2022 252.211-7008 Use of Government-Assigned Serial Numbers SEP 2010 252.215-7013 Supplies and Services Provided by Nontraditional Defense

Contractors

JAN 2023

252.223-7008 Prohibition of Hexavalent Chromium JAN 2023 252.225-7020 Trade Agreements Certificate--Basic NOV 2014 252.225-7021 Trade Agreements--Basic DEC 2022 252.225-7050 Disclosure of Ownership or Control by the Government of a

Country that is a State Sponsor of Terrorism

DEC 2022

252.225-7055 Representation Regarding Business Operations with the Maduro Regime

MAY 2022

252.225-7056 Prohibition Regarding Business Operations with the Maduro Regime

MAY 2022

252.225-7972 (Dev) Prohibition on the Procurement of Foreign-Made Unmanned Aircraft Systems (DEVIATION 2020-O0015)

MAY 2020

252.225-7973 (Dev) Prohibition on the Procurement of Foreign-Made Unmanned Aircraft Systems - Representation (DEVIATION 2020- O0015)

MAY 2020

252.227-7015 Technical Data--Commercial Products and Commercial Services

MAR 2023

252.227-7037 Validation of Restrictive Markings on Technical Data JAN 2023 252.232-7003 Electronic Submission of Payment Requests and Receiving

Reports

DEC 2018

252.232-7010 Levies on Contract Payments DEC 2006

252.232-7017 Accelerating Payments to Small Business Subcontractors-- Prohibition on Fees and Consideration

DEC 2022

252.244-7000 Subcontracts for Commercial Items DEC 2022 252.247-7023 Transportation of Supplies by Sea FEB 2019

CLAUSES INCORPORATED BY FULL TEXT

52.204-24 REPRESENTATION REGARDING CERTAIN TELECOMMUNICATIONS AND VIDEO

SURVEILLANCE SERVICES OR EQUIPMENT (NOV 2021)

The Offeror shall not complete the representation at paragraph (d)(1) of this provision if the Offeror has represented that it "does not provide covered telecommunications equipment or services as a part of its offered products or services to the Government in the performance of any contract, subcontract, or other contractual instrument" in paragraph (c)(1) in the provision at 52.204-26, Covered Telecommunications Equipment or Services-- Representation, or in paragraph (v)(2)(i) of the provision at 52.212-3, Offeror Representations and Certifications- Commercial Products and Commercial Services. The Offeror shall not complete the representation in paragraph (d)(2) of this provision if the Offeror has represented that it "does not use covered telecommunications equipment or services, or any equipment, system, or service that uses covered telecommunications equipment or services" in paragraph (c)(2) of the provision at 52.204-26, or in paragraph (v)(2)(ii) of the provision at 52.212-3.

(a) Definitions. As used in this provision-

Backhaul, covered telecommunications equipment or services, critical technology, interconnection arrangements, reasonable inquiry, roaming, and substantial or essential component have the meanings provided in the clause 52.204-25, Prohibition on Contracting for Certain Telecommunications and Video Surveillance Services or Equipment.

(b) Prohibition.

(1) Section 889(a)(1)(A) of the John S. McCain National Defense Authorization Act for Fiscal Year 2019 (Pub. L.

115-232) prohibits the head of an executive agency on or after August 13, 2019, from procuring or obtaining, or extending or renewing a contract to procure or obtain, any equipment, system, or service that uses covered telecommunications equipment or services as a substantial or essential component of any system, or as critical technology as part of any system. Nothing in the prohibition shall be construed to--

(i) Prohibit the head of an executive agency from procuring with an entity to provide a service that connects to the facilities of a third-party, such as backhaul, roaming, or interconnection arrangements; or

(ii) Cover telecommunications equipment that cannot route or redirect user data traffic or cannot permit visibility into any user data or packets that such equipment transmits or otherwise handles.

(2) Section 889(a)(1)(B) of the John S. McCain National Defense Authorization Act for Fiscal Year 2019 (Pub. L.

115-232) prohibits the head of an executive agency on or after August 13, 2020, from entering into a contract or extending or renewing a contract with an entity that uses any equipment, system, or service that uses covered telecommunications equipment or services as a substantial or essential component of any system, or as critical technology as part of any system. This prohibition applies to the use of covered telecommunications equipment or services, regardless of whether that use is in performance of work under a Federal contract. Nothing in the prohibition shall be construed to--

(i) Prohibit the head of an executive agency from procuring with an entity to provide a service that connects to the facilities of a third-party, such as backhaul, roaming, or interconnection arrangements; or

(ii) Cover telecommunications equipment that cannot route or redirect user data traffic or cannot permit visibility into any user data or packets that such equipment transmits or otherwise handles.

(c) Procedures. The Offeror shall review the list of excluded parties in the System for Award Management (SAM) (https://www.sam.gov) for entities excluded from receiving federal awards for "covered telecommunications equipment or services."

(d) Representations. The Offeror represents that--

(1) It [ ___ ] will, [ ___ ] will not provide covered telecommunications equipment or services to the Government in the performance of any contract, subcontract or other contractual instrument resulting from this solicitation. The Offeror shall provide the additional disclosure information required at paragraph (e)(1) of this section if the Offeror responds "will" in paragraph (d)(1) of this section; and

(2) After conducting a reasonable inquiry, for purposes of this representation, the Offeror represents that--

It [ ___ ] does, [ ___ ] does not use covered telecommunications equipment or services, or use any equipment, system, or service that uses covered telecommunications equipment or services. The Offeror shall provide the additional disclosure information required at paragraph (e)(2) of this section if the Offeror responds "does" in paragraph (d)(2) of this section.

(e) Disclosures.

(1) Disclosure for the representation in paragraph (d)(1) of this provision. If the Offeror has responded "will" in the representation in paragraph (d)(1) of this provision, the Offeror shall provide the following information as part of the offer:

(i) For covered equipment--

(A) The entity that produced the covered telecommunications equipment (include entity name, unique entity identifier, CAGE code, and whether the entity was the original equipment manufacturer (OEM) or a distributor, if known);

(B) A description of all covered telecommunications equipment offered (include brand; model number, such as OEM number, manufacturer part number, or wholesaler number; and item description, as applicable); and

(C) Explanation of the proposed use of covered telecommunications equipment and any factors relevant to determining if such use would be permissible under the prohibition in paragraph (b)(1) of this provision.

(ii) For covered services--

(A) If the service is related to item maintenance: A description of all covered telecommunications services offered (include on the item being maintained: Brand; model number, such as OEM number, manufacturer part number, or wholesaler number; and item description, as applicable); or

(B) If not associated with maintenance, the Product Service Code (PSC) of the service being provided; and explanation of the proposed use of covered telecommunications services and any factors relevant to determining if such use would be permissible under the prohibition in paragraph (b)(1) of this provision.

(2) Disclosure for the representation in paragraph (d)(2) of this provision. If the Offeror has responded "does" in the representation in paragraph (d)(2) of this provision, the Offeror shall provide the following information as part of the offer:

(i) For covered equipment--

(A) The entity that produced the covered telecommunications equipment (include entity name, unique entity identifier, CAGE code, and whether the entity was the OEM or a distributor, if known);

(B) A description of all covered telecommunications equipment offered (include brand; model number, such as OEM number, manufacturer part number, or wholesaler number; and item description, as applicable); and

(C) Explanation of the proposed use of covered telecommunications equipment and any factors relevant to determining if such use would be permissible under the prohibition in paragraph (b)(2) of this provision.

(ii) For covered services--

(A) If the service is related to item maintenance: A description of all covered telecommunications services offered (include on the item being maintained: Brand; model number, such as OEM number, manufacturer part number, or wholesaler number; and item description, as applicable); or

(B) If not associated with maintenance, the PSC of the service being provided; and explanation of the proposed use of covered telecommunications services and any factors relevant to determining if such use would be permissible under the prohibition in paragraph (b)(2) of this provision.

(End of provision)

52.211-14 NOTICE OF PRIORITY RATING FOR NATIONAL DEFENSE, EMERGENCY PREPAREDNESS, AND ENERGY PROGRAM USE (APR 2008)

Any contract awarded as a result of this solicitation will be [ ] DX rated order; [ X ] DO rated order certified for national defense, emergency preparedness, and energy program use under the Defense Priorities and Allocations System (DPAS) (15 CFR 700), and the Contractor will be required to follow all of the requirements of this regulation.

52.212-3 OFFEROR REPRESENTATIONS AND CERTIFICATIONS - COMMERCIAL PRODUCTS AND

COMMERCIAL SERVICES (DEVIATION 2023-O0002) (DEC 2022) ALTERNATE I (OCT 2014)

The Offeror shall complete only paragraph (b) of this provision if the Offeror has completed the annual representations and certification electronically in the System for Award Management (SAM) accessed through https://www.sam.gov. If the Offeror has not completed the annual representations and certifications electronically, the Offeror shall complete only paragraphs (c) through (v) of this provision.

(a) Definitions. As used in this provision - Covered telecommunications equipment or services has the meaning provided in the clause 52.204-25, Prohibition on Contracting for Certain Telecommunications and Video Surveillance Services or Equipment.

Economically disadvantaged women-owned small business (EDWOSB) concern means a small business concern that is at least 51 percent directly and unconditionally owned by, and the management and daily business operations of which are controlled by, one or more women who are citizens of the United States and who are economically disadvantaged in accordance with 13 CFR part 127, and the concern is certified by SBA or an approved third-party certifier in accordance with 13 CFR 127.300. It automatically qualifies as a women-owned small business eligible under the WOSB Program.

Forced or indentured child labor means all work or service -

(1) Exacted from any person under the age of 18 under the menace of any penalty for its nonperformance and for which the worker does not offer himself voluntarily; or

(2) Performed by any person under the age of 18 pursuant to a contract the enforcement of which can be accomplished by process or penalties.

Highest-level owner means the entity that owns or controls an immediate owner of the offeror, or that owns or controls one or more entities that control an immediate owner of the offeror. No entity owns or exercises control of the highest level owner.

Immediate owner means an entity, other than the offeror, that has direct control of the offeror. Indicators of control include, but are not limited to, one or more of the following: Ownership or interlocking management, identity of interests among family members, shared facilities and equipment, and the common use of employees.

Inverted domestic corporation means a foreign incorporated entity that meets the definition of an inverted domestic corporation under 6 U.S.C. 395(b), applied in accordance with the rules and definitions of 6 U.S.C. 395(c).

Manufactured end product means any end product in product and service codes (PSCs) 1000-9999, except -

(1) PSC 5510, Lumber and Related Basic Wood Materials;

(2) Product or Service Group (PSG) 87, Agricultural Supplies;

(3) PSG 88, Live Animals;

(4) PSG 89, Subsistence;

(5) PSC 9410, Crude Grades of Plant Materials;

(6) PSC 9430, Miscellaneous Crude Animal Products, Inedible;

(7) PSC 9440, Miscellaneous Crude Agricultural and Forestry Products;

(8) PSC 9610, Ores;

(9) PSC 9620, Minerals, Natural and Synthetic; and

(10) PSC 9630, Additive Metal Materials.

Place of manufacture means the place where an end product is assembled out of components, or otherwise made or processed from raw materials into the finished product that is to be provided to the Government. If a product is disassembled and reassembled, the place of reassembly is not the place of manufacture.

Predecessor means an entity that is replaced by a successor and includes any predecessors of the predecessor.

Reasonable inquiry has the meaning provided in the clause 52.204-25, Prohibition on Contracting for Certain Telecommunications and Video Surveillance Services or Equipment.

Restricted business operations means business operations in Sudan that include power production activities, mineral extraction activities, oil-related activities, or the production of military equipment, as those terms are defined in the Sudan Accountability and Divestment Act of 2007 (Pub. L. 110-174). Restricted business operations do not include business operations that the person (as that term is defined in Section 2 of the Sudan Accountability and Divestment Act of 2007) conducting the business can demonstrate -

(1) Are conducted under contract directly and exclusively with the regional government of southern Sudan;

(2) Are conducted pursuant to specific authorization from the Office of Foreign Assets Control in the Department of the Treasury, or are expressly exempted under Federal law from the requirement to be conducted under such authorization;

(3) Consist of providing goods or services to marginalized populations of Sudan;

(4) Consist of providing goods or services to an internationally recognized peacekeeping force or humanitarian organization;

(5) Consist of providing goods or services that are used only to promote health or education; or

(6) Have been voluntarily suspended.

Sensitive technology -

(1) Means hardware, software, telecommunications equipment, or any other technology that is to be used specifically -

(i) To restrict the free flow of unbiased information in Iran; or

(ii) To disrupt, monitor, or otherwise restrict speech of the people of Iran; and

(2) Does not include information or informational materials the export of which the President does not have the authority to regulate or prohibit pursuant to section 203(b)(3) of the International Emergency Economic Powers Act (50 U.S.C. 1702(b)(3)).

Service-disabled veteran-owned small business concern -

(1) Means a small business concern -

(i) Not less than 51 percent of which is owned by one or more service - disabled veterans or, in the case of any publicly owned business, not less than 51 percent of the stock of which is owned by one or more service-disabled veterans; and

(ii) The management and daily business operations of which are controlled by one or more service-disabled veterans or, in the case of a service-disabled veteran with permanent and severe disability, the spouse or permanent caregiver of such veteran.

(2) Service-disabled veteran means a veteran, as defined in 38 U.S.C. 101(2), with a disability that is service-connected, as defined in 38 U.S.C. 101(16).

Small business concern –

(1) Means a concern, including its affiliates, that is independently owned and operated, not dominant in its field of operation, and qualified as a small business under the criteria in 13 CFR part 121 and size standards in this solicitation.

(2) Affiliates, as used in this definition, means business concerns, one of whom directly or indirectly controls or has the power to control the others, or a third party or parties control or have the power to control the others. In determining whether affiliation exists, consideration is given to all appropriate factors including common ownership, common management, and contractual relationships. SBA determines affiliation based on the factors set forth at 13

CFR 121.103.

Small disadvantaged business concern, consistent with 13 CFR 124.1002, means a small business concern under the size standard applicable to the acquisition, that -

(1) Is at least 51 percent unconditionally and directly owned (as defined at 13 CFR 124.105) by -

(i) One or more socially disadvantaged (as defined at 13 CFR 124.103) and economically disadvantaged (as defined at 13 CFR 124.104) individuals who are citizens of the United States; and

(ii) Each individual claiming economic disadvantage has a net worth not exceeding $850,000 after taking into account the applicable exclusions set forth at 13 CFR 124.104(c)(2); and

(2) The management and daily business operations of which are controlled (as defined at 13.CFR 124.106) by individuals, who meet the criteria in paragraphs (1)(i) and (ii) of this definition.

Subsidiary means an entity in which more than 50 percent of the entity is owned -

(1) Directly by a parent corporation; or

(2) Through another subsidiary of a parent corporation.

Successor means an entity that has replaced a predecessor by acquiring the assets and carrying out the affairs of the predecessor under a new name (often through acquisition or merger). The term “successor” does not include new offices/divisions of the same company or a company that only changes its name. The extent of the responsibility of the successor for the liabilities of the predecessor may vary, depending on State law and specific circumstances.

Veteran-owned small business concern means a small business concern -

(1) Not less than 51 percent of which is owned by one or more veterans (as defined at 38 U.S.C. 101(2)) or, in the case of any publicly owned business, not less than 51 percent of the stock of which is owned by one or more veterans; and

(2) The management and daily business operations of which are controlled by one or more veterans.

Women-owned business concern means a concern which is at least 51 percent owned by one or more women; or in the case of any publicly owned business, at least 51 percent of its stock is owned by one or more women; and whose management and daily business operations are controlled by one or more women.

Women-owned small business concern means a small business concern -

(1) That is at least 51 percent owned by one or more women; or, in the case of any publicly owned business, at least 51 percent of the stock of which is owned by one or more women; and

(2) Whose management and daily business operations are controlled by one or more women.

Women-owned small business (WOSB) concern eligible under the WOSB Program (in accordance with 13 CFR part 127), means a small business concern that is at least 51 percent directly and unconditionally owned by, and the management and daily business operations of which are controlled by, one or more women who are citizens of the United States, and the concern is certified by SBA or an approved third-party certifier in accordance with 13 CFR 127.300.

(b)(1) Annual Representations and Certifications. Any changes provided by the Offeror in paragraph (b)(2) of this provision do not automatically change the representations and certifications in SAM.

(2) The offeror has completed the annual representations and certifications electronically in SAM accessed through http://www.sam.gov. After reviewing SAM information, the Offeror verifies by submission of this offer that the representations and certifications currently posted electronically at FAR 52.212-3, Offeror Representations and Certifications - Commercial Products and Commercial Services, have been entered or updated in the last 12 months, are current, accurate, complete, and applicable to this solicitation (including the business size standard(s) applicable to the NAICS code(s) referenced for this solicitation), at the time this offer is submitted and are incorporated in this offer by reference (see FAR 4.1201), except for paragraphs ___ .

[Offeror to identify the applicable paragraphs at (c) through (v) of this provision that the offeror has completed for the purposes of this solicitation only, if any.

These amended representation(s) and/or certification(s) are also incorporated in this offer and are current, accurate, and complete as of the date of this offer.

Any changes provided by the offeror are applicable to this solicitation only, and do not result in an update to the representations and certifications posted electronically on SAM.]

(c) Offerors must complete the following representations when the resulting contract is for supplies to be delivered or services to be performed in the United States or its outlying areas, or when the contracting officer has applied part 19 in accordance with 19.000(b)(1)(ii). Check all that apply.

(1) Small business concern. The offeror represents as part of its offer that -

(i) It [ ___ ] is, [ ___ ] is not a small business concern; or

(ii) It [ ___ ] is, [ ___ ] is not a small business joint venture that complies with the requirements of 13 CFR 121.103(h) and 13 CFR 125.8(a) and (b). [The offeror shall enter the name and unique entity identifier of each party to the joint venture: ___ .]

(2) Veteran-owned small business concern. [Complete only if the offeror represented itself as a small business concern in paragraph (c)(1) of this provision.] The offeror represents as part of its offer that it [ ___ ] is, [ ___ ] is not a veteran-owned small business concern.

(3) Service-disabled veteran-owned small business concern. [Complete only if the offeror represented itself as a veteran-owned small business concern in paragraph (c)(2) of this provision.] The offeror represents as part of its offer that -

(i) It [ ___ ] is, [ ___ ] is not a service-disabled veteran-owned small business concern; or

(ii) It [ ___ ] is, [ ___ ] is not a joint venture that complies with the requirements of 13 CFR 125.18(b)(1) and (2).

[The offeror shall enter the name and unique entity identifier of each party to the joint venture: ___ .] Each service-disabled veteran-owned small business concern participating in the joint venture shall provide representation of its service-disabled veteran-owned small business concern status.

(4) Small disadvantaged business concern. [Complete only if the offeror represented itself as a small business concern in paragraph (c)(1) of this provision.] The offeror represents that it [ ___ ] is, [ ___ ] is not a small disadvantaged business concern as defined in 13 CFR 124.1002.

(5) Women-owned small business concern. [Complete only if the offeror represented itself as a small business concern in paragraph (c)(1) of this provision.] The offeror represents that it [ ___ ] is, [ ___ ] is not a women-owned small business concern.

(6) WOSB joint venture eligible under the WOSB Program. The offeror represents that it [ ___ ] is, [ ___ ] is not a joint venture that complies with the requirements of 13 CFR 127.506(a) through (c). [The offeror shall enter the name and unique entity identifier of each party to the joint venture: ___ .]

(7) Economically disadvantaged women-owned small business (EDWOSB) joint venture. The offeror represents that it [ ___ ] is, [ ___ ] is not a joint venture that complies with the requirements of 13 CFR 127.506(a) through (c).

[The offeror shall enter the name and unique entity identifier of each party to the joint venture: ___ .] Note to paragraphs (c)(8) and (9):

Complete paragraphs (c)(8) and (9) only if this solicitation is expected to exceed the simplified acquisition threshold.

(8) Women-owned business concern (other than small business concern). [Complete only if the offeror is a women-owned business concern and did not represent itself as a small business concern in paragraph (c)(1) of this provision.] The offeror represents that it [ ___ ] is, a women-owned business concern.

(9) Tie bid priority for labor surplus area concerns. If this is an invitation for bid, small business offerors may identify the labor surplus areas in which costs to be incurred on account of manufacturing or production (by offeror or first-tier subcontractors) amount to more than 50 percent of the contract price:

(10) HUBZone small business concern. [Complete only if the offeror represented itself as a small business concern in paragraph (c)(1) of this provision.] The offeror represents, as part of its offer, that -

(i) It [ ___ ] is, [ ___ ] is not a HUBZone small business concern listed, on the date of this representation, as having been certified by SBA as a HUBZone small business concern in the Dynamic Small Business Search and SAM, and will attempt to maintain an employment rate of HUBZone residents of 35 percent of its employees during performance of a HUBZone contract (see 13 CFR 126.200(e)(1)); and

(ii) It [ ___ ] is, [ ___ ] is not a HUBZone joint venture that complies with the requirements of 13 CFR 126.616(a) through (c). [The offeror shall enter the name and unique entity identifier of each party to the joint venture: ___ .] Each HUBZone small business concern participating in the HUBZone joint venture shall provide representation of its HUBZone status.

(11) (Complete if the offeror has represented itself as disadvantaged in paragraph (c)(4) of this provision.)

[ ___ ] Black American.

[ ___ ] Hispanic American.

[ ___ ] Native American (American Indians, Eskimos, Aleuts, or Native Hawaiians).

[ ___ ] Asian-Pacific American (persons with origins from Burma, Thailand, Malaysia, Indonesia, Singapore, Brunei, Japan, China, Taiwan, Laos, Cambodia (Kampuchea), Vietnam, Korea, The Philippines, Republic of Palau, Republic of the Marshall Islands, Federated States of Micronesia, the Commonwealth of the Northern Mariana Islands, Guam, Samoa, Macao, Hong Kong, Fiji, Tonga, Kiribati, Tuvalu, or Nauru).

[ ___ ] Subcontinent Asian (Asian-Indian) American (persons with origins from India, Pakistan, Bangladesh, Sri Lanka, Bhutan, the Maldives Islands, or Nepal).

[ ___ ] Individual/concern, other than one of the…