RFP 70RFP223REC000010.pdf

SEE ADDENDUMIS CHECKED

CODE 18a. PAYMENT WILL BE MADE BY

CODE

FACILITYCODE

17b. CHECK IF REMITTANCE IS DIFFERENT AND PUT SUCH ADDRESS IN OFFER

OFFEROR

OPO/FPS/EACCG/R11/B

Philadelphia PA 19106

701 Market Street, Suite 3200 Ofc of Procurement Operations - FPS U.S. Dept. of Homeland Security DHS/FPS/East CCG/Region 11/Group B

CODE 16. ADMINISTERED BYCODE

X

X

X

561612

SIZE STANDARD:

100.00 % FOR:SET ASIDE:UNRESTRICTED OR70RFP2

RFPIFB

10. THIS ACQUISITION ISCODE

RFQ

14. METHOD OF SOLICITATION

13b. RATING

NAICS:

SMALL BUSINESS

10/04/2023

Joshua Clemens (No collect calls)

INFORMATION CALL:

FOR SOLICITATION 8. OFFER DUE DATE/LOCAL TIME

10/19/2023 1400 ET

b. TELEPHONE NUMBERa. NAME

4. ORDER NUMBER3. AWARD/ 6. SOLICITATION

70RFP223REC000010

5. SOLICITATION NUMBER

SOLICITATION/CONTRACT/ORDER FOR COMMERCIAL ITEMS 1. REQUISITION NUMBER PAGE OF

1 5 OFFEROR TO COMPLETE BLOCKS 12, 17, 23, 24, & 30

Attn: Josh Clemens

TELEPHONE NO.

17a. CONTRACTOR/

See Task Order Requirements

15. DELIVER TO

Philadelphia PA 19106 701 Market Street, Suite 3200 Federal Protective Service Acq. Division Office of Procurement Operations U.S. Dept. of Homeland Security

9. ISSUED BY

7.

2. CONTRACT NO.

EFFECTIVE DATE

$29

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

ISSUE DATE

DELIVERY FOR FOB DESTINA-

TION UNLESS BLOCK IS

MARKED

11.

SEE SCHEDULEX

12. DISCOUNT TERMS

THIS CONTRACT IS A

RATED ORDER UNDER

DPAS (15 CFR 700)

13a.

SERVICE-DISABLED

VETERAN-OWNED

SMALL BUSINESS

HUBZONE SMALL

BUSINESS

8(A)

FPS EAST CCG DIV 2 ACQ DIV(70RFP2)

WOMEN-OWNED SMALL BUSINESS

(WOSB) ELIGIBLE UNDER THE WOMEN-OWNED

SMALL BUSINESS PROGRAM

EDWOSB

24.

AMOUNT

23.

UNIT PRICE

22.

UNIT

21.

QUANTITY

20.

SCHEDULE OF SUPPLIES/SERVICES

19.

ITEM NO.

A. The Department of Homeland Security (DHS), Federal Protective Service Acquisitions Division (FPSAD) is issuing this Request for Proposals (RFP) to solicit offers for armed Protective Security Officer services at federally leased or owned facilities. The Government anticipates awarding multiple indefinite delivery/indefinite quantity (ID/IQ) contracts with fixed priced provisions from this solicitation utilizing FAR 12/15 procedures.

(Use Reverse and/or Attach Additional Sheets as Necessary)

HEREIN, IS ACCEPTED AS TO ITEMS:

XX

DATED . YOUR OFFER ON SOLICITATION (BLOCK 5),

INCLUDING ANY ADDITIONS OR CHANGES WHICH ARE SET FORTH

COPIES TO ISSUING OFFICE. CONTRACTOR AGREES TO FURNISH AND DELIVER

ARE

ARE

31c. DATE SIGNED

27b. CONTRACT/PURCHASE ORDER INCORPORATES BY REFERENCE FAR 52.212-4. FAR 52.212-5 IS ATTACHED. ADDENDA

31a. UNITED STATES OF AMERICA (SIGNATURE OF CONTRACTING OFFICER)

30c. DATE SIGNED 31b. NAME OF CONTRACTING OFFICER (Type or print)

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

SHEETS SUBJECT TO THE TERMS AND CONDITIONS SPECIFIED.

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

26. TOTAL AWARD AMOUNT (For Govt. Use Only)

OFFER

STANDARD FORM 1449 (REV. 2/2012)

Prescribed by GSA - FAR (48 CFR) 53.212

ARE NOT ATTACHED.

ARE NOT ATTACHED.

AUTHORIZED FOR LOCAL REPRODUCTION

PREVIOUS EDITION IS NOT USABLE

30b. NAME AND TITLE OF SIGNER (Type or print)

30a. SIGNATURE OF OFFEROR/CONTRACTOR

28. CONTRACTOR IS REQUIRED TO SIGN THIS DOCUMENT AND RETURN

25. ACCOUNTING AND APPROPRIATION DATA

29. AWARD OF CONTRACT:

REF.

X

Track #1 Unrestricted/Track #2 Set-Aside 100% for Small Business

32e. MAILING ADDRESS OF AUTHORIZED GOVERNMENT REPRESENTATIVE

32c. DATE 32b. SIGNATURE OF AUTHORIZED GOVERNMENT REPRESENTATIVE

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

32a. QUANTITY IN COLUMN 21 HAS BEEN

RECEIVED INSPECTED

40. PAID BY39. S/R VOUCHER NUMBER38. S/R ACCOUNT NUMBER

37. CHECK NUMBER

FINALPARTIAL

36. PAYMENT

FINALPARTIAL

35. AMOUNT VERIFIED

CORRECT FOR

34. VOUCHER NUMBER33. SHIP NUMBER

COMPLETE

32g. E-MAIL OF AUTHORIZED GOVERNMENT REPRESENTATIVE

42d. TOTAL CONTAINERS42c. DATE REC'D (YY/MM/DD)

42b. RECEIVED AT (Location)

42a. RECEIVED BY (Print)

41c. DATE41b. SIGNATURE AND TITLE OF CERTIFYING OFFICER

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

STANDARD FORM 1449 (REV. 2/2012) BACK

24.

AMOUNT

23.

UNIT PRICE

22.

UNIT

21.

QUANTITY

20.

SCHEDULE OF SUPPLIES/SERVICES

19.

ITEM NO.

Please note that there are two tracks under this

RFP. Track #1 is issued under full and open competition while Track #2 is set-aside 100% for small business concerns.

Task orders will be issued off this contract vehicle in accordance with FAR 16.505.

B. Minimum and Maximum Quantities:

As referred to in paragraph (b) of the

"Indefinite Quantity" clause of this contract, the total contract minimum quantity is a total of

$10,000.00 worth of orders per contract at the contract hourly rate(s). This minimum guarantee will be de-obligated from the resultant contract once a task order or task orders is/are issued with a value of $10,000.00 or greater through which the minimum guarantee will then be satisfied. The contractor can only invoice for the minimum guarantee as applied at the resultant contract level if task orders are never issued against the resultant contract and only at the end of the contract's period of performance. If task orders are issued, but do not amount to a value of $10,000.00, the contractor can invoice for the minimum guarantee minus the total value of the task orders issued under the resultant contract at the end of the resultant contract's period of performance.

Continued ...

32f. TELEPHONE NUMBER OF AUTHORIZED GOVERNMENT REPRESENTATIVE

32d. PRINTED NAME AND TITLE OF AUTHORIZED GOVERNMENT REPRESENTATIVE

5 2 of

ITEM NO. SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT

NAME OF OFFEROR OR CONTRACTOR

3 5

CONTINUATION SHEET

REFERENCE NO. OF DOCUMENT BEING CONTINUED PAGE OF

(A) (B) (C) (D) (E) (F)

70RFP223REC000010

After you download the RFP, please review the entire RFP thoroughly and completely, including

ALL ATTACHMENTS that are attached within the paperclip icon on the left side of this RFP.

C. Ordering Procedures for Task Orders:

Pursuant to FAR 16.504 (a)(4)(iv), the following are the procedures that the Government will use in issuing orders, including the ordering media and the procedures and selection criteria that the Government will use to provide awardees a fair opportunity to be considered for each order:

1. FPSAD will issue a Request for Quotations

(RFQ) typically via e-mail to all contract holders under either Track #1 or Track #2 depending on the requirement, unless a fair opportunity exception applies (see FAR 16.505).

2. The RFQ will typically include a SF1449 with a period of performance, due date for the quotation submission, the post exhibit delineating the post coverage for the requirement, any applicable wage determination(s), seniority list if applicable, additional task order requirements if applicable

(over and above the contract requirements) and other information pertinent to the requirement

(e.g., make and model of weapon) to help contract holders put together a quotation. Transition time at the task order level will vary and may range from as little as several hours to 120 days depending on the requirement.

3. Contract holders will generally be provided a reasonable response time (typically 1-5 days) to prepare and submit quotations although more complex requirements may result in additional response time. If a contract holder does not submit a quotation for a requirement, a detailed explanation on why a quote was not submitted must be received within 24 hours of the RFQ closing time/date. At the task order level, contractors shall have the requisite facility clearance, if required, as specified in the RFQ at the commencement of task order performance.

4. Regarding quotation requirements, a written or oral price quotation shall always be required in response to the RFQ. Contractors are permitted to quote rates lower than those originally proposed and awarded in their contracts although

Continued ...

NSN 7540-01-152-8067 OPTIONAL FORM 336 (4-86)

Sponsored by GSA

FAR (48 CFR) 53.110

4 5

CONTINUATION SHEET

REFERENCE NO. OF DOCUMENT BEING CONTINUED PAGE OF

(A) (B) (C) (D) (E) (F)

70RFP223REC000010

contractors cannot exceed its hourly rates in their contract unless authorized by the

Contracting Officer in the RFQ. Discounted labor rates will only apply to the respective task order and will not change the fixed rates established in the contract.

5. Regarding the evaluation of task order quotations, evaluation criteria will be specified with the Request for Quotations (i.e., best value or low price). Upon completion of evaluations, the contracting office will issue a task order to the contractor whose quotation is deemed most advantageous to the Government based on the stated evaluation factors in the RFQ. When required by FAR 16.505, an e-mail will be sent to all unsuccessful contractors with the awardee's overall price for each task order issued, and if applicable, the rationale for award for requirements competed on a basis other than price in accordance with FAR 16.505.

6. Task order evaluations will be conducted under

FAR subpart 16.5 (Indefinite-Delivery Contracts).

FAR subpart 15.3 (Source Selection) will not apply to the evaluation of task order competitions for this requirement. The Government reserves the right to communicate with vendors regarding their quotes and seek corrections, without forming a competitive range or entering into discussions. The Government may conduct communication with one, some, none or all vendors at its discretion. Such communication will not be considered discussions.

Offerors shall only fill out the pricing schedule CLINS for the track(s) they are submitting a proposal (Track 1 Unrestricted complete CLINS 0001 and 0002; Track 2 Small Business Set Aside CLINS 0003 and 0004).

Track #1

Unrestricted

Requires Top Secret Facility Clearance at time of RFP closing

0001 PSO Services 25000000 HR

Anticipated Award Type: Indefinite-quantity

Continued ...

NSN 7540-01-152-8067 OPTIONAL FORM 336 (4-86)

5 5

CONTINUATION SHEET

REFERENCE NO. OF DOCUMENT BEING CONTINUED PAGE OF

(A) (B) (C) (D) (E) (F)

70RFP223REC000010

Period of Performance: 11/01/2023 to 10/31/2028

0002 Supervisory PSO Services 2500000 HR

Anticipated Award Type: Indefinite-quantity

Period of Performance: 11/01/2023 to 10/31/2028

Track #2

100% Set-Aside for Small Business

0003 PSO Services 10000000 HR

Anticipated Award Type: Indefinite-quantity

Period of Performance: 01/01/2024 to 12/31/2028

0004 Supervisory PSO Services 1000000 HR

Product/Service Code: S206

Product/Service Description: HOUSEKEEPING- GUARD

Period of Performance: 01/01/2024 to 12/31/2028

NSN 7540-01-152-8067 OPTIONAL FORM 336 (4-86)

Model for Price Realism

Model for Price Realism - Attachment 5 70RFP223REC000010

Applicable: Prevailing WD(s)/CBA(s):

PRICING ELEMENT Ordering Period 1 Total

Regular Hourly Wage Rate Proposed

Health and Welfare Hourly Rate Proposed

Total Productive Hours Proposed - 0

Total Regular Wage Direct Labor $ - 0

- 0

Shift Differential Pay - 0

Bonus/Performance Pay - 0

Subtotal - Productive Labor $ - 0 $ - 0

PSO Fringe Benefits and Non-Productive Time

Health and Welfare $ - 0

Pension - 0

401K Matching - 0

- 0

Holiday - 0

Vacation - 0

Sick - 0

Training - 0

Other - 0

Sub-Total Fringe Benefits and Non-Productive Time $ - 0 $ - 0

Taxes

FICA $ - 0

FUTA - 0

SUTA - 0

Other - 0

Sub-Total Taxes $ - 0 $ - 0

Overhead $ - 0

Other Direct Elements (Reference Note 1)

Workman's Comp Insurance $ - 0

General Liability Ins - 0

Uniforms - 0

Body Armor - 0

Weapons - 0

Ammunition - 0

Personal Protection Equipment - 0

Targets - 0

Travel - 0

Guard License Fees - 0

Medical/Physical Fitness/Drug Screen - 0

Other Start-Up/Transition - 0

- 0

- 0

- 0

Computer Usage Charges (Storage, Mainframe, Internet) - 0

Third Party Systems (e.g. Post Confirmation System) - 0

- 0

- 0

Consultants/Professional fees - 0

Other:

XXXXX - 0

XXXXX - 0

XXXXX - 0

Sub-Total - Other Direct Elements $ - 0 $ - 0

Non-PSO Positions (See Non-PSO Positions Tab for additional Price Info Required) $ - 0 $ - 0

General and Administrative $ - 0

Total Price w/o Profit $ - 0 $ - 0

Profit $ - 0

Grand Total $ - 0 $ - 0

Basic Rate

Explanatory Notes

Note 1 - Fringe Benefits, Non-Productive Time, and Other Direct Element Pricing

Signature and Title of Preparer

(&"Arial,Italic"Name of Company&"Arial,Regular") Price Element Breakdown for Solicitation (&"Arial,Italic"RFQ or RFP #&"Arial,Regular") &D

For the purpose of this price breakdown model, these elements should be separately broken out as shown, even if it is the contractor's accounting practice to include these items in their Overhead and/or G&A rate. However, the contractor should reduce their reported Overhead and G&A amounts for the impact of these separately identified price elements to the extent they are already included in their Overhead and G&A. This will ensure that price elements are not duplicated in the breakdown.

Non-PSO Positions

Proposed FTEs, Hours, and Costs for Non-PSO Positions

Ordering Period 1 Total Hours/Costs Priced

Full Time Equivalents Total Hours Priced Total Costs without G&A or Profit Total Hours Priced Total Costs without G&A or Profit

Contract Manager(s) - 0 $ - 0

- 0 - 0

Supervisors (Additional) - 0 - 0

Quality Control Personnel - 0 - 0

- 0 - 0

Training Instructor(s) - 0 - 0

Admin - 0 - 0

Additional Positions:

XXX - 0 - 0

XXX - 0 - 0

XXX - 0 - 0

Total - 0 - 0 $ - 0 - 0 $ - 0

Instructions (also see Price Element Breakdown Instructions)

a. The purpose of this worksheet is to provide additional pricing information regarding the Non-PSO Positions that are included in your Firm Fixed Price price build-up. Please note that the Total Costs without G&A or Profit for each period will automatically populate the Non-PSO position cells on the "Model for Price Realism" tab. Any applicable G&A and profit for the non-PSO positions should be priced on the "Model for Price Realism" tab" on the G&A and Profit lines (Rows 74 and 78).

b. For purposes of this worksheet, full-time equivalent employees equal the number of employees on full-time schedules plus the number of employees on part-time schedules converted to a full-time basis to staff the contract. For instance, if 5,000 hours are quoted for a particular position and on average the annual productive hours of a full time employee for that position is 1800 hours (e.g. 2080 less 80 holiday less 160 vacation leave less 40 sick), the equivalent FTE to staff the labor category is calculated as 5000/1800 = 2.8 FTE. Note that for staffing to an FTE level, a contractor may use a combination of full time and part time employees. This information shall be entered in the applicable cells for each Non-PSO Position category. This information may be used for Government Price Realism evaluation purposes.

FTEs, Nonproductive Hrs

PSO FTEs, Non-Productive Hours per FTE

Ordering Period 1

PSO Full Time Equivalents Proposed

Vacation Hours per FTE

Sick/Personal Hours per FTE

Holiday Hours per FTE

Training Hours per FTE

Instructions:

In the cells above, input the number of proposed Full Time Equivalent (FTE) PSOs, Vacation Hours per FTE, Sick/Personal Hours Per FTE, Holiday Hours Per FTE, Training Hours per FTE. These amounts shall correspond to the costs presented on the Model for Price Realism tab. Note, not all of the non-productive hour categories listed above may pertain to your proposal. Accordingly, only input values for those categories that are included in the price build up prepared on the Model for Price Realism spreadsheet.

The input above is based on a pricing strategy that utilizes Full Time Equivalent calculations as a basis of estimate for non-productive hours. If a different pricing strategy was utilized, vendors should alter this spreadsheet to provide similar information based on their unique pricing strategy . The data inputted in this spreadsheet does not automatically populate any other spreadsheet and is not used in any formulas contained in this workbook.

In the text box below, provide a narrative describing the basis of the proposed PSO FTEs , each applicable non-productive hour category. Describe any unique factors that may impact the estimate(s). For example, if the estimates consider certain non-productive hour categories do not pertain to all PSOs (e.g. part time PSOs), then the narrative should clearly explain the impact.

This information may be used for Government Price Realism evaluation purposes.

Narrative Description of the Basis of the PSO Full Time Equivalents and Non-Productive Hours Proposed

Model for Price Realism

Model for Price Realism - Supervisory PSO's - Attachment 5 70RFP223REC000010

April 2022 Version

PRICING ELEMENT Ordering Period 1 Total

Regular Hourly Wage Rate Proposed

Health and Welfare Hourly Rate Proposed

Total Productive Hours Proposed - 0

Total Regular Wage Direct Labor $ - 0 $ - 0

- 0

- 0

Bonus/Performance Pay - 0

Subtotal - Productive Labor $ - 0 $ - 0

Supervisory PSO Fringe Benefits and Non-Productive Time

Health and Welfare $ - 0

Pension - 0

- 0

- 0

Holiday - 0

Vacation - 0

Sick - 0

- 0

- 0

- 0

Training - 0

- 0

- 0

Other - 0

Sub-Total Fringe Benefits and Non-Productive Time $ - 0 $ - 0

Taxes

FICA $ - 0

FUTA - 0

SUTA - 0

Other - 0

Sub-Total Taxes $ - 0 $ - 0

Overhead $ - 0

Other Direct Elements (Reference Note 1)

Workman's Comp Insurance $ - 0

General Liability Ins - 0

Uniforms - 0

Body Armor - 0

Weapons - 0

Ammunition - 0

Personal Protection Equipment - 0

Targets - 0

Travel - 0

Guard License Fees - 0

Medical/Physical Fitness/Drug Screen - 0

Other Start-Up/Transition - 0

- 0

- 0

- 0

Computer Usage Charges (Storage, Mainframe, Internet) - 0

Third Party Systems (e.g. Post Confirmation System) - 0

- 0

- 0

Consultants/Professional fees - 0

Other:

XXXXX - 0

XXXXX - 0

XXXXX - 0

Sub-Total - Other Direct Elements $ - 0 $ - 0

General and Administrative $ - 0

Total Price w/o Profit $ - 0 $ - 0

Profit $ - 0

Grand Total $ - 0 $ - 0

Basic Rate

Explanatory Notes

Supervisors are not considered service contract labor and vendors will not be entitled to SCA wage adjustments to the supervisory bill rates.

Note 1 - Fringe Benefits, Non-Productive Time, and Other Direct Element Pricing

Signature and Title of Preparer

(&"Arial,Italic"Name of Company&"Arial,Regular") Price Element Breakdown for Solicitation (&"Arial,Italic"RFQ or RFP #&"Arial,Regular") &D

For the purpose of this price breakdown model, these elements should be separately broken out as shown, even if it is the contractor's accounting practice to include these items in their Overhead and/or G&A rate. However, the contractor should reduce their reported Overhead and G&A amounts for the impact of these separately identified price elements to the extent they are already included in their Overhead and G&A. This will ensure that price elements are not duplicated in the breakdown.

FTEs, Nonproductive Hrs, Supervisory PSO FTEs, Non-Productive Hours per FTE

Ordering Period 1

Supervisor Full Time Equivalents Proposed

Vacation Hours per FTE

Sick/Personal Hours per FTE

Holiday Hours per FTE

Training Hours per FTE

Instructions:

In the cells above, input the number of proposed Full Time Equivalent (FTE) Supervisory PSOs, Vacation Hours per FTE, Sick/Personal Hours Per FTE, Holiday Hours Per FTE, Training Hours per FTE. These amounts shall correspond to the costs presented on the Model for Price Realism tab. Note, not all of the non-productive hour categories listed above may pertain to your proposal. Accordingly, only input values for those categories that are included in the price build up prepared on the Model for Price Realism spreadsheet.

The input above is based on a pricing strategy that utilizes Full Time Equivalent calculations as a basis of estimate for non-productive hours. If a different pricing strategy was utilized, vendors should alter this spreadsheet to provide similar information based on their unique pricing strategy . The data inputted in this spreadsheet does not automatically populate any other spreadsheet and is not used in any formulas contained in this workbook.

In the text box below, provide a narrative describing the basis of the proposed Supervisor FTEs , each applicable non-productive hour category. Describe any unique factors that may impact the estimate(s). For example, if the estimates consider certain non-productive hour categories do not pertain to all Supervisory PSOs (e.g. part time Supervisory PSOs), then the narrative should clearly explain the impact.

This information may be used for Government Price Realism evaluation purposes.

Narrative Description of the Basis of the Supervisory PSO Full Time Equivalents and Non-Productive Hours Proposed

Exhibit 1 List of Required Forms

Item Form Number Title Section

Reference

1 DD 254 DoD Contract Security Classification Specification, when applicable 5.7.1

2 DD 441 DoD Security Agreement, when applicable 5.7.5

3 DHS Form 11000-6 Non-Disclosure Agreement 7.2.5

4 DHS Form 11000-9 Disclosure and Authorization Pertaining to Consumer Reports pursuant to the Fair Credit Reporting Act

5.3.4

5 FD 258 Fingerprint Card Application 5.3.4

6 OF-306 Declaration for Federal Employment 5.3.4

7 SF 85 Questionnaire for Public Trust Positions 5.3.4

8 SF 85-P Supplemental Questionnaire for Selected Positions 5.3.4

9 SF 86 Questionnaire for National Security Positions, when applicable 5.9.1

10 USCIS Form I-9 Employment Eligibility Verification 7.2.5

11 CIWRC V2. Apr14 Contractor Information Worksheet 5.3.4

FPS CIW V4. FEB 2015

Federal Protective Service

CONTRACTOR INFORMATION WORKSHEET (CIW)

Request Type: Please select the type of request Date (MM/DD/YYYY) New Request

Periodic Re-Investigation Position Change Name Change

Contract Change Dual Contract

Separation Reason For Separation:

Section I: Requesting Official/Organization

Contracting Officer Representative (COR) (1)

Name (Last, First) Region Select Region

Phone Email

Prime Contractor POC (1)

Name (Last, First MI)

Phone Email

Prime Company (1) Company Name Contract Number

Section II: Individual to be Screened

Full Name (1) Last First Middle

Position Title (1)

Social Security Number (1) Date of Birth(MM/DD/YYYY)

Place of Birth City State Country (if not US)

E-Mail Address

Daytime Phone Number

Section III: For UNCLASSIFIED CONTRACTS, Position Designation

Low Risk Moderate Risk (5N) High Risk (6N)

Section IV: For CLASSIFIED CONTRACTS ONLY, Position Security Clearance Requirement

Secret Top Secret

*For FPS reference only. Clearance adjudications must be facilitated by the contractor’s FSO and adjudicated by Defense Security Services.

**When available, a Visitor Authorization Request (VAR) letter must be submitted with the CIW.

Privacy Act Information Authority: 5 U.S.C. § 301; 44 U.S.C. § 3101; Homeland Security Act of 2002, Pub. L. No. 107-296, 116 Stat. 2135; Executive Order (EO) 9397; EO 10450; EO 12968;

and 5 CFR Part 731 authorize the collection of this information.

Purpose: The primary purpose of this collection is to facilitate the screening of an individual for a contractor position to perform services for the Federal government.

Routine Uses: The information collected may be disclosed as generally permitted under 5 U.S.C. § 552a (b) of the Privacy Act of 1974, as amended. This includes using the information as necessary and authorized by the routine uses published in DHS/ALL-023 - Department of Homeland Security Personnel Security Management, 75 FR8088 (February 23, 2010).

Disclosure: Participation is voluntary; however, failure to provide this information may delay the individual from being able to perform services for the Federal Government.

(1) Denotes fields required for completing an Exit Request.

FPS CIW V4. FEB 2015

Instructions – Completing the Contractor Information Worksheet

General

The FPS Contractor Information Worksheet (CIW) is used by Contractor Officer’s Representatives (COR) to request that the Personnel Security Division (PSD) or the Regional Contract Adjudications (RCA) units perform appropriate fitness screening on contractor employees associated with Protective Security Officer Program.

Section – Request Type

Please enter the date of the request, and select one of the following request types:

• New Request – Select “New Request” when the contractor employee is new to FPS.

• Position Change – Select “Position Change” when the contractor obtains a new position associated with the PSO contract.

• Contract Change – Select “Contract Change” if the contractor employee is changing PSO contracts.

• Periodic Re-Investigation – Select “Periodic Reinvestigation” when the contractor is due for their updated e-QIP and associated investigation.

• Name Change – Select “Name Change” if the contractor employee has legally changed their name.

o When “Name Change” is the Request Type, documentation supporting the name change shall be attached.

• Dual Contractor – Select “Dual Contractor” when the contractor is currently serving on an existing PSO contract.

• Separation – Select “Separation” when the contractor employee has left the contract o When “Separation” is the Request Type, a reason shall be indicated on the CIW.

Section I – Requesting Official/Organization

Please complete all fields in Section I.

• Requesting Official – Only the Contracting Officer’s Representative (COR) can be the requesting official.

Section II – Individual to be screened

Please complete all fields in Section II.

Section III – Position Designation

The position designation is essential to the contractor fitness process as it determines the Investigative requirements associated with the position. For example the minimum investigative standard for a Moderate Risk Position is a Moderate Background Investigation (MBI) completed within the last five years. For FPS, the minimum position designation for any Protective Security Officer (PSO) is Moderate Risk. If during the fitness process it is determined that the individual has been investigated by another Federal agency, FPS will use this investigation whenever practical. There are designated costs associated with each level of investigation. Therefore it is critical that the appropriate position designation be made on the CIW, to avoid unnecessary expenditures of time and funds.

Please select only one.

Section IV – Position Security Clearance Requirement

On Classified Contracts, some or all positions may require access to national security information (NSI). In this instance, the contractor employee must have an active clearance at, or higher than, the level designated by the FPS position. Please note, FPS does not grant security clearances to contract employees.

Please complete this section for positions associated with CLASSIFIED contracts. When practical, submit a Visitor Authorization Request (VAR) sent to you from the company Facility Security Officer. FPS will validate this information with Defense Security Services and update the DHS Integrated Security Management System accordingly.

Electronic Transmittal of the CIW

Important: FPS PSD and RCA units will only accept a CIW submitted by FPS CO, COTR, or Federal Points of Contacts. CIW forms submitted by Contractor Employees or Contractor Company representatives will not be processed. A completed worksheet includes Sensitive Personal Identification Information and requires encryption outside of the DHS network.

INSTRUCTIONS for PSO PIV CARD REVOCATION & DESTRUCTION REQUEST [Only use for those personnel no longer employed on a PSO Security Services contract]

Column A: Enter the PIV Card Holder's full legal name, i.e.; as provided on a birth certificate, Social Security Card, or driver's license, etc.

Column B: Enter the Type of Identifier and the PIV Card Holder's EDIPI or Person Handle Identifier Number (Both identifiers can be located in ISMS) Example: EDIPI: 1234567890 or PH: 0123456789 (must be a 10-digit number)

Column C: Identify the PIV Card Holder's position title [Use the drop-down selector for Protective Security Officer, Key Personnel, or Staff]

Column D: Enter the HSPD-12 PIV Card number located on the back of the card; example: 1000002156 DHS001-7000-02104

Column E: Use the drop-down to select [Cessation of Operation]

Column F: Identify the Region the applicant is supporting [Use the drop-down selector for Region 1 through Region 11]

Column G: Enter the Contracting Officer's Representative (COR) name

Column H: Enter the Prime Contractor Name

Column I: Enter the Prime Contract Number [Not Telephone Number]

FOR GOVERNMENT ONLY

Column J: Enter the Name of the Federal Employee that destroyed the PIV card

Column K: Enter the Date that the PIV card was destroyed **NOTE** The PIV Card shall be destroyed using a cross-cut shredder

Column L: Enter the FPS 3155 Case Number for all Lost or Stolen PIV Cards [*PIV Cards not returned to the COR upon exiting contract]

NOTES

*The COR shall email the completed worksheet to the FPS HSPD-12 Program Office at: FPSHQHSPD-12@ice.dhs.gov

*The FPS HSPD-12 Program Office will review and validate the Integrated Security Management System (ISMS) and the Identity Management System (IDMS) to ensure profiles are updated appropriately

*Once the review is complete, the FPS HSPD-12 Program Office will provide the COR with a current status update

EXHIBIT 2a

PSO Security Services Contracts HSPD-

12 PIV Card Request

POC: FPS HSPD-12 Program Office

FPSHQHSPD-12@hq.dhs.gov

(703) 235-6187

Applicant's Full Legal Name (Last/First/Middle) Applicant's EDIPI or Person Handle Position Title Reason Weapons Bearer FERO FPS Region COR Name (First/Last) Prime Contractor Name Prime Contract Number Comments

Protective Security Officer New Yes Approved Region 1

Key Personnel Inoperable No Disapproved Region 2

Staff Replace (Damaged) Region 3

Replace (Expired) Region 4

Replace (Lost) Region 5

Replace (Stolen) Region 6

Replace (Name Change) Region 7

Other Region 8

Region 9

Region 10

Region 11

*The FPS HSPD-12 Program Office will review and validate the Integrated Security Management System (ISMS) and the Identity Management System (IDMS) to ensure the applicant has a current and valid profile

*Once the review is complete, the FPS HSPD-12 Program Office will provide the COR with a sponsorship notice or current status, if not able to sponsor

Column H: Enter the name of the Contracting Officer's Representative (COR)

Column I: Enter the Prime Contractor Name

Column J: Enter the Prime Contract Number

*The COR shall email the completed worksheet to the FPS HSPD-12 Program Office at FPSHQHSPD-12@hq.dhs.gov

INSTRUCTIONS. [Prior to submitting a request, CORs should validate that the contractor employee has an active and current ISMS profile (with correct personal and contract information) and (at a minimum) a Pre-App Decision Granted/Date (aka: Entry on Duty) for the contract identified in Column J]

Column A: Enter the applicant's full legal name, i.e.; as provided on a birth certificate, Social Security Card, or driver's license, etc.

Column B: Enter the Type of Identifier and the applicant's EDIPI or Person Handle Identifier Number (Both identifiers can be located in ISMS) Example: EDIPI: 2354633 or PH: 0023433

Column C: Identify the applicant's position title [Use the drop-down selector for Protective Security Officer, Key Personnel, Staff]

Column D: Identify the applicant's reason for a HSPD-12 PIV Card [Use the drop-down to select the appropriate reason] NOTE: If the Reason is for Replace (Lost/Stolen) a FPS 3155, Incident Report, Case Number shall be entered into the Comments Section (Column K)

Column E: Identify the applicant's need for Weapons Bearer on the HSPD-12 PIV Card [Use the drop-down to select Yes or No] PSOs Only

Column F: Identify the applicant's need for the Federal Emergency Response Official (FERO) Stripe on the HSPD-12 PIV Card [Use the drop-down to select Yes or No] PSOs Only

Column G: Identify the Region the applicant is supporting [Use the drop-down selector for Region 1 through Region 11

Exhibit 2a

PSO Security Services Contracts

HSPD-12 PIV Card Revocation/Destruction

PIV Card Holder Full Legal Name (Last/First/Middle) PIV Card Holder's EDIPI or Person Handle Position Title HSPD-12 PIV Card Number Reason** FPS Region COR Name (First/Last) Prime Contractor Name Prime Contract Number Destroyed by: (Last/First Name) Destroyed Date 3155 Case #

FOR GOVERNMENT ONLY

Protective Security Officer Cessation of Operation Region 1

Key Personnel Key Compromised Region 2

Staff Superseded Region 3

Region 4

Region 5

Region 6

Region 7

Region 8

Region 9

Region 10

Region 11

*Once the review is complete, the FPS HSPD-12 Program Office will provide the COR with a current status update

*The FPS HSPD-12 Program Office will review and validate the Integrated Security Management System (ISMS) and the Identity Management System (IDMS) to ensure profiles are updated appropriately

*The COR shall email the completed worksheet to the FPS HSPD-12 Program Office at FPSHQHSPD-12@hq.dhs.gov

Column K: Enter the Date that the PIV card was destoryed **NOTE** The PIV Card shall be destroyed using a cross-cut shredder

Column L: Enter the FPS 3155 Case Number for all Lost or Stolen PIV Cards

Column J: Enter the Name of the Federal Employee that destroyed the PIV card **NOTE** The PIV Card shall be destroyed using a cross-cut shredder

Column I: Enter the Prime Contract Number

Column H: Enter the Prime Contractor Name

Column G: Enter the Contracting Officer's Representative (COR) name

Column F: Identify the Region the applicant is supporting [Use the drop-down selector for Region 1 through Region 11

**Superseded: A PIV Card Holder has a change in clearance or any other change to the card topology, to include damaged or inoperable cards

**Key Compromised: A PIV Card is lost or stolen. **NOTE** Shall provide the 3155 Case Number in Column L.

POC: FPS HSPD-12 Program Office FPSHQHSPD-12@fps,dhs.gov (703) 235-6187

**Cessation of Operation: A PIV Card Holder is retiring, resigning, or is fired

Column E: Identify the reason for HSPD-12 PIV Card Return [Use the drop-down to select the appropriate reason - definitions below]

Column D: Enter the HSPD-12 PIV Card number located on the botton of the card; example: 1000002156 DHS001-7000-02104

Column B: Enter the Type of Identifier and the PIV Card Holder's EDIPI or Person Handle Identifier (Both can be located in ISMS) Example: EDIPI 2345433 or PH 5465324

Column A: Enter the PIV Card Holder's full legal name, i.e.; as provided on a birth certificate, Social Security Card, or driver's license, etc.

INSTRUCTIONS

Column C: Identify the applicant's position title [Use the drop-down selector for Protective Security Officer, Key Personnel, or Staff]

Exhibit 2a

DEPARTMENT OF HOMELAND SECURITY

NON-DISCLOSURE AGREEMENT

Protected Critical Infrastructure Information (PCII)

Agreement in consideration of my being granted conditional access to certain information, specified below, that is owned by, produced by, or in the possession of the United States Government.

(Signer will acknowledge the category or categories of information that he or she may have access to, and the signer's willingness to comply with the standards for protection by placing his or her initials in front of the applicable category or categories.)

Initials:

I attest that I am familiar with, and I will comply with all requirements of the PCII program set out in the Critical Infrastructure Information Act of 2002 (CII Act) (Title II, Subtitle B, of the Homeland Security Act of 2002, Public Law 107-296, 196 Stat. 2135, 6 USC 101 et seq.), as amended, the implementing regulations thereto (6 CFR Part 29), as amended, and the applicable PCII Procedures Manual, as amended, and with any such requirements that may be officially communicated to me by the PCII Program Manager or the PCII Program Manager's designee.

Sensitive Security Information (SSI)Initials:

I attest that I am familiar with, and I will comply with the standards for access, dissemination, handling, and safeguarding of SSI information as cited in this Agreement and in accordance with 49 CFR Part 1520, "Protection of Sensitive Security Information," "Policies and Procedures for Safeguarding and Control of SSI," as amended, and any supplementary guidance issued by an authorized official of the Department of Homeland Security.

Other Sensitive but Unclassified (SBU)Initials:

As used in this Agreement, sensitive but unclassified information is an over-arching term that covers any information, not otherwise indicated above, which the loss of, misuse of, or unauthorized access to or modification of could interfere with the national interest or the conduct of Federal programs, or the privacy to which individuals are entitled under Section 552a of Title 5, as amended, but which has not been specifically authorized under criteria established by an Executive Order or an Act of Congress to be kept secret in the interest of national defense or foreign policy. This includes information categorized by DHS or other government agencies as: For Official Use Only (FOUO); Official Use Only (OUO); Sensitive Homeland Security Information (SHSI); Limited Official Use (LOU); Law Enforcement Sensitive (LES);

Safeguarding Information (SGI); Unclassified Controlled Nuclear Information (UCNI); and any other identifier used by other government agencies to categorize information as sensitive but unclassified.

I attest that I am familiar with, and I will comply with the standards for access, dissemination, handling, and safeguarding of the information to which I am granted access as cited in this Agreement and in accordance with the guidance provided to me relative to the specific category of information.

I understand and agree to the following terms and conditions of my access to the information indicated above:

3. I attest that I understand my responsibilities and that I am familiar with and will comply with the standards for protecting such information that I may have access to in accordance with the terms of this Agreement and the laws, regulations, and/ or directives applicable to the specific categories of information to which I am granted access. I understand that the United States Government may conduct inspections, at any time or place, for the purpose of ensuring compliance with the conditions for access, dissemination, handling and safeguarding information under this Agreement.

I, , an individual official, employee, consultant, or subcontractor of or to

(the Authorized Entity), intending to be legally bound, hereby consent to the terms in this

1. I hereby acknowledge that I have received a security indoctrination concerning the nature and protection of information to which I have been provided conditional access, including the procedures to be followed in ascertaining whether other persons to whom I contemplate disclosing this information have been approved for access to it, and that I understand these procedures.

2. By being granted conditional access to the information indicated above, the United States Government has placed special confidence and trust in me and I am obligated to protect this information from unauthorized disclosure, in accordance with the terms of this Agreement and the laws, regulations, and directives applicable to the specific categories of information to which I am granted access.

DHS Form 11000-6 (10/18)

Exhibit 3

8. If I violate the terms and conditions of this Agreement, such violation may result in the cancellation of my conditional access to the information covered by this Agreement. This may serve as a basis for denying me conditional access to other types of information, to include classified national security information.

4. I will not disclose or release any information provided to me pursuant to this Agreement without proper authority or authorization. Should situations arise that warrant the disclosure or release of such information I will do so only under approved circumstances and in accordance with the laws, regulations, or directives applicable to the specific categories of information. I will honor and comply with any and all dissemination restrictions cited or verbally relayed to me by the proper authority.

5. (a) For PCII - (1) Upon the completion of my engagement as an employee, consultant, or subcontractor under the contract, or the completion of my work on the PCII Program, whichever occurs first, I will surrender promptly to the PCII Program Manager or his designee, or to the appropriate PCII officer, PCII of any type whatsoever that is in my possession.

(2) If the Authorized Entity is a United States Government contractor performing services in support of the PCII Program, I will not request, obtain, maintain, or use PCII unless the PCII Program Manager or Program Manager's designee has first made in writing, with respect to the contractor, the certification as provided for in Section 29.8(c) of the implementing regulations to the CII Act, as amended.

(b) For SSI and SBU - I hereby agree that material which I have in my possession and containing information covered by this Agreement, will be handled and safeguarded in a manner that affords sufficient protection to prevent the unauthorized disclosure of or inadvertent access to such information, consistent with the laws, regulations, or directives applicable to the specific categories of information. I agree that I shall return all information to which I have had access or which is in my possession 1) upon demand by an authorized individual; and/or 2) upon the conclusion of my duties, association, or support to DHS; and/or 3) upon the determination that my official duties do not require further access to such information.

6. I hereby agree that I will not alter or remove markings, which indicate a category of information or require specific handling instructions, from any material I may come in contact with, in the case of SSI or SBU, unless such alteration or removal is consistent with the requirements set forth in the laws, regulations, or directives applicable to the specific category of information or, in the case of PCII, unless such alteration or removal is authorized by the PCII Program Manager or the PCII Program Manager's designee. I agree that if I use information from a sensitive document or other medium, I will carry forward any markings or other required restrictions to derivative products, and will protect them in the same matter as the original.

7. I hereby agree that I shall promptly report to the appropriate official, in accordance with the guidance issued for the applicable category of information, any loss, theft, misuse, misplacement, unauthorized disclosure, or other security violation, I have knowledge of and whether or not I am personally involved. I also understand that my anonymity will be kept to the extent possible when reporting security violations.

9. (a) With respect to SSI and SBU, I hereby assign to the United States Government all royalties, remunerations, and emoluments that have resulted, will result, or may result from any disclosure, publication, or revelation of the information not consistent with the terms of this Agreement.

(b) With respect to PCII I hereby assign to the entity owning the PCII and the United States Government, all royalties, remunerations, and emoluments that have resulted, will result, or may result from any disclosure, publication, or revelation of PCII not consistent with the terms of this Agreement.

10. This Agreement is made and intended for the benefit of the United States Government and may be enforced by the United States Government or the Authorized Entity. By granting me conditional access to information in this context, the United States Government and, with respect to PCII, the Authorized Entity, may seek any remedy available to it to enforce this Agreement including, but not limited to, application for a court order prohibiting disclosure of information in breach of this Agreement. I understand that if I violate the terms and conditions of this Agreement, I could be subjected to administrative, disciplinary, civil, or criminal action, as appropriate, under the laws, regulations, or directives applicable to the category of information involved and neither the United States Government nor the Authorized Entity have waived any statutory or common law evidentiary privileges or protections that they may assert in any administrative or court proceeding to protect any sensitive information to which I have been given conditional access under the terms of this Agreement.

Page 2 of 3DHS Form 11000-6 (10/18)

11. Unless and until I am released in writing by an authorized representative of the Department of Homeland Security (if permissible for the particular category of information), I understand that all conditions and obligations imposed upon me by this Agreement apply during the time that I am granted conditional access, and at all times thereafter.

12. Each provision of this Agreement is severable. If a court should find any provision of this Agreement to be unenforceable, all other provisions shall remain in full force and effect.

13. My execution of this Agreement shall not nullify or affect in any manner any other secrecy or non-disclosure Agreement which I have executed or may execute with the United States Government or any of its departments or agencies.

14. These provisions are consistent with and do not supersede, conflict with, or otherwise alter the employee obligations, rights, or liabilities created by existing statute or Executive Order relating to (1) classified information, (2) communications to Congress, (3) the reporting to an Inspector General of a violation of any law, rule, or regulation, or mismanagement, a gross waste of funds, an abuse of authority, or a substantial and specific danger to public health or safety, or (4) any other whistleblower protection. The definitions, requirements, obligations, rights, sanctions, and liabilities created by controlling Executive Orders and statutory provisions are incorporated into this agreement and are controlling.

15. Signing this Agreement does not bar disclosures to Congress or to an authorized official of an executive agency or the Department of Justice that are essential to reporting a substantial violation of law.

16. I represent and warrant that I have the authority to enter into this Agreement.

17. I have read this Agreement carefully and my questions, if any, have been answered. I acknowledge that the briefing officer has made available to me any laws, regulations, or directives referenced in this document so that I may read them at this time, if I so choose.

NON-DISCLOSURE AGREEMENT

Acknowledgement Typed/Printed Name: Government/Department/Agency/Business Address Telephone Number:

Typed/Printed Name: Government/Department/Agency/Business Address Telephone Number:

I make this Agreement in good faith, without mental reservation or purpose of evasion.

Signature:

WITNESS:

This form is not subject to the requirements of P.L. 104-13, "Paperwork Reduction Act of 1995" 44 USC, Chapter 35.

Date:

Signature: Date:

DHS Form 11000-6 (10/18) Page 3 of 3

Exhibit 4

DISCLOSURE AND AUTHORIZATION

PERTAINING TO CONSUMER REPORTS

PURSUANT TO THE FAIR CREDIT REPORTING ACT

This is a release for the Department of Homeland Security to obtain one or more consumer/credit reports about you in connection with your application for employment or in the course of your employment with the Department. One or more reports about you may be obtained for employment purposes, including evaluating your fitness for employment, promotion, reassignment, retention, or access to classified information and/or sensitive, but unclassified information.

I, , hereby authorized the Department of Homeland Security to obtain such report(s) from any consumer/credit reporting agency for employment purposes. Copies of this authorization that show my signature are as valid as the original signed by me.

Signature

Date

Social Security Number

Current Organization Assigned

The Privacy Act, 5 U.S.C. 552a, requires that federal agencies inform individuals, at the time information is solicited from them, whether the disclosure is mandatory or voluntary, by what authority such information is solicited, and what uses will be made of the information. You are hereby advised that authority for soliciting your Social Security Number (SSN) is Executive Order 9397. Your SSN will be used to identify you precisely when it is necessary to conduct and/or obtain a credit report on you. Although the disclosure of your SSN is not mandatory, your failure to do so may impede the acquisition of a credit report concerning you and possibly result in the denial of your being approved for access to classified and/or sensitive, but unclassified information.

DHS Form 11000-9 (10/08)

Lautenberg Amendment Certification (Exhibit 5)

FACT SHEET

On September 30, 1996, Title 18, United States Code, Section 922 (g)(9), was signed into law. This legislation makes it illegal for anyone who has been convicted of a misdemeanor crime of domestic violence to possess, receive, ship or transport any firearm or ammunition. This law applies without exception to any person who has ever been convicted of a misdemeanor crime of domestic violence within the meaning of the statute. The inability of an individual to lawfully possess a firearm disqualifies that person from any position authorizing firearm privileges.

The position for which you have applied authorizes firearm privileges. Therefore, in order to determine your qualifications for this position, you must complete a certification form. Please carefully review the statute and all of the following information before responding to the inquiry.

QUALIFICATION INQUIRY – Prospective New FPS LEO

For new applicants, you must complete the Lautenberg Certification Form and return it following instructions provided. In completing the form, you are advised that:

• The purpose is to obtain information regarding your qualification to possess or receive firearms or ammunition.

• You must complete and return the form in a timely manner to receive consideration for the position to which you are applying. If you fail to complete and/or return the form in a timely manner you will automatically be deemed not qualified.

REQUALIFICATION INQUIRY – Current FPS LEOs

Current FPS LEOs must complete the Lautenberg Certification Form annually, when provided by your supervisor at the time of their performance review.

THE LAW

The Lautenberg Amendment to Title 18, U.S.C., Section 922 (g) provides:

(g) It shall be unlawful for any person –

(9) who has been convicted in any court of a misdemeanor crime of…