Sensitive_Security_Information_Acknowledgement_Form.docx

DOCX document 20 KB Posted

Attached to
Fully Insured Vision Benefits
Solicitation number
RFP PS-26-0317
Issued by
Maricopa County, Phoenix City, Arizona

About this file

This is a Sensitive Security Information Acknowledgement Form issued by the City of Phoenix Aviation Department for use in connection with a project involving documents controlled under 49 C.F.R. Parts 15 and 1520. The form serves as a binding acknowledgement that authorized representatives of bidding companies understand the restricted nature of security-sensitive information and agree to comply with federal regulations governing its disclosure and handling. Signatories must confirm their company's commitment to limiting access to individuals with a demonstrated "need to know" and to destroy all specified documents upon completion of their review and use or by the contract end date, whichever occurs earlier. The form requires the authorized representative's printed name, signature, title, phone number, and complete company address.

This acknowledgement form is associated with the City of Phoenix's solicitation for fully insured vision benefits under a five-year contract commencing on or about January 1, 2028. The procurement process will be conducted through the City's Procurement Portal, with technical support available for portal-related issues. The contract will become effective upon City Council award and signature and recording by the City Clerk's department, in accordance with Phoenix City Code requirements. The agreement will terminate upon the earliest occurrence of reaching the end of the contract term, including any exercised extensions, or upon termination pursuant to specific agreement provisions. Respondents should direct procurement-related questions to the designated procurement officer.

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Text version

EXHIBIT __

City of Phoenix Aviation Department Sensitive Security Information Acknowledgement Form

The documents entitled [fill in document title(s)] (“Documents”) to be used as part of the [fill in project name] contain Sensitive Security Information that is controlled under 49 C.F.R. Parts 15 and 1520. These documents may only be disclosed to persons who have the requisite “need to know”, as defined in 49 C.F.R. Parts 15 and 1520. Unauthorized release of this information may result in civil penalty or other action. For U.S. government agencies, public disclosure is governed by 5 U.S.C. 552 and 49 C.F.R. Parts 15 and 1520.

I acknowledge, on my behalf and that of my company, the above statement and agree to destroy the [fill in document title(s)], in compliance with 49 C.F.R. Parts 15 and 1520, upon the earlier of our company’s completion of our need to review and/or use the Documents or no later than [fill in current contract end date].

NAME OF COMPANY

AUTHORIZED REPRESENTATIVE PRINTED NAME

AUTHORIZED REPRESENTATIVE’S SIGNATURE

______
TITLEPHONE NUMBER

ADDRESS CITY, STATE AND ZIP CODE

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