Foreign_Interest_Determination_questionaire_5531-1_10-13_(rev_2).pdf

FOREIGN INTEREST DETERMINATION Ref: OPNAVINST N9210.3 & NAVSEAINST 5510.2 (Type or print all answers)

PENALTY NOTICE

Failure to answer all questions or any misrepresentation (by omission or concealment, or by misleading, false or partial answers) may serve as a basis for denial of access to Naval Nuclear Propulsion Information (NNPI) and/or NAVSEA facilities. In addition, Title 18, United States Code 1001, makes it a criminal offense, punishable by a maximum of five

(5) years imprisonment, $15,000 fine, or both, to knowingly make a false statement or representation to any Department or Agency of the United States, as to any matter within the jurisdiction of any Department or Agency of the United States. This includes any statement made herein which is knowingly incorrect, incomplete or misleading in any important particular.

PROVISIONS

1. This report addresses requirements of DOD 5220.22-M, OPNAVINST N9210.3, and NAVSEAINST 5510.2. While you are not required to respond, your eligibility cannot be determined if you do not complete this form. Access to NNPI and/or NAVSEA facilities is contingent upon your compliance with the requirements of OPNAVINST N9210.3 or

NAVSEAINST 5510.2.

2. When this report is submitted in confidence and is so marked, applicable exemptions to the Freedom of Information Act will be invoked to withhold it from public disclosure.

3. Complete all questions on this form. Mark "Yes" or 'No" for each question. If your answer is "Yes" furnish, in full, the complete information under "Remarks."

QUESTIONS AND ANSWERS

YES NO

1. (Answer 1a or 1b)

a. (For entities which issue stock): Do any foreign person(s) directly or indirectly, own or have beneficial ownership of 5 percent or more of the outstanding shares of any class of your organization's equity securities?

b. (For entities which do not issue stock): Has any foreign person, directly or indirectly, subscribed 5 percent or more of your organization's total capital commitment?

2. Does your organization directly, or indirectly through your subsidiaries and/or affiliates, own 10 percent or more of any foreign interest?

3. Do any non-U.S. citizens or persons holding dual citizenship serve as members of your organization's board of directors (or similar governing body), officers, executive personnel, general partners, regents, trustees, or senior management officials?

4. Does any foreign person(s) have the power, direct or indirect, to control the election, appointment, or tenure of members of your organization's board of directors (or similar governing body) or other management positions of your organization, or have the power to control or cause the direction of other decisions or activities of your organization?

5. Does your organization have any contracts, agreements, understandings, or arrangements with a foreign person(s)?

6. Does your organization, whether as borrower, surety, guarantor, or otherwise have any indebtedness, liabilities, or obligations to a foreign person(s)?

7. During your last fiscal year, did your organization derive:

a. 5 percent or more of its total revenues or net income from any single foreign person?

b. In the aggregate, 30 percent or more of its revenues or net income from foreign persons?

8. Is 10 percent or more of any class of your organization's voting securities held in "nominee" shares, in "street names," or in some other method which does not identify the beneficial owner?

9. Do any of the members of your organization's board of directors (or similar governing body), officers, executive personnel, general partners, regents, trustees, or senior management officials hold any positions with, or serve as consultants for, any foreign person(s)?

10. Is there any other factor(s) that indicates or demonstrates a capability on the part of foreign persons to control or influence the operations or management of your organization?

PSNS&IMF 5531/1 (Rev. 11-13) (Front)

FOREIGN INTEREST DETERMINATION

REMARKS (Attach additional sheets, if necessary, for a full detailed statement.)

CERTIFICATION

I CERTIFY that the entries made by me above are true, complete, and correct to the best of my knowledge and belief and are made in good faith.

WITNESSES:

(Date Certified)

By

(Signature of Authorized Contractor Representative)

(Typed Name of Contractor)

(Title of Authorized Contractor Representative)

NOTE: In case of a corporation, a witness is not required but the certificate below must be completed. Type or print names under all signatures.

(Address)

NOTE: Contractor, if a corporation, should cause the following certificate to be executed under its corporate seal, provided that the same officer shall not execute both the Agreement and the Certificate.

CERTIFICATE

I, , certify that I am the of the corporation named as Contractor herein; that who signed this certificate on behalf of the Contractor, was then , of said corporation; that said certificate was duly signed for and in behalf of said corporation by authority of its governing body, and is within the scope of its corporate powers.

(Corporate Seal)

(Signature and Date)

PSNS&IMF 5531/1 (Rev. 11-13) (Back)