SBU Information Request Form.doc

{This form is for the offeror’s/contractor’s use if drawings or other sensitive but unclassified building information will be requested by the offeror/contractor. This certification should be incorporated into the Representations and Certifications section of the construction solicitation template and separated with a page break from the previous page.}

REQUEST FOR SENSITIVE BUT UNCLASSIFIED BUILDING (SBU) INFORMATION

Solicitation/Contract Number ________________________________________

The requester shall complete the information below and return the entire Request for Sensitive but Unclassified Building (SBU) Information document to the Contracting Officer or Contract Specialist. By signature below, the requestor of SBU building information acknowledges the requirement to maintain controls, as stated herein, to safeguard the information, and shall return or destroy the SBU building information as required by this Agreement. The undersigned acknowledges that the requester shall abide by this Agreement and shall only disseminate SBU building information to other authorized users under the conditions set forth herein.

Company Name: _____________________________________________________ Name of Individual and Title: ____________________________________________

Signature: ___________________________________________________

Date: _______________________________________________________

(The Offeror shall attach copy of business license or formation document.)

DUNS Number: _________________________________________

DUNS Number Verified by Government Representative at: https://www.sam.gov/portal/public/SAM/#1

Yes: ___ No: ___

Employer ID Number/Federal Tax ID Number _______________________________

Offeror/bidder/contractor information and DUNS number has been verified and release of SBU building information is approved by:

[Contracting Officer's Name]

Date Contracting Officer This statement shall be submitted by the holder of SBU building information when information is disposed of in accordance with the Request for Sensitive but Unclassified Building Information upon completion of the Project.}

DISPOSAL STATEMENT FOR SENSITIVE BUT UNCLASSIFIED BUILDING INFORMATION

Solicitation/Contract Number ________________________________________ I hereby certify that all Sensitive but Unclassified (SBU) building information relative to the referenced solicitation/contract not previously returned to the Government has been destroyed or disposed of by burning or shredding paper copies, physically destroying computer diskettes or permanently deleting/removing/erasing electronic files from computers.

I also certify the no unauthorized physical or electronic copies of such SBU building information were made or are being retained.

Company Name: ______________________________________________

Name of Individual: ____________________________________________

Signature: ___________________________________________________

Title: _______________________________________________________

Date: _________________

Revised 6/24/2015