Sensitive_Security_Information_Acknowledgement_Form.docx
DOCX document 20 KB Posted
- Attached to
- Independent Medical Evaluation Services
- Solicitation number
- RTM RFP 26-001
- Issued by
- Maricopa County, Phoenix City, Arizona
About this file
This is a Sensitive Security Information Acknowledgement Form from the City of Phoenix Aviation Department. The form establishes protocols for handling documents containing Sensitive Security Information controlled under 49 C.F.R. Parts 15 and 1520. The document requires authorized representatives from bidding companies to acknowledge receipt of specified documents related to a project and to confirm their understanding that disclosure of this information is limited to persons with a demonstrated "need to know" as defined in federal regulations. Signatories agree to comply with all applicable federal security protocols and commit to destroying the documents upon the earlier of either their company's completion of its review and use of the materials or the specified contract end date.
The form does not contain pricing terms, set-asides, incumbent information, or funding details, as it serves solely as an acknowledgment mechanism for security compliance. The document is a template with blank fields to be completed with specific document titles, project names, company information, authorized representative details, and contract end dates. Unauthorized release of the Sensitive Security Information may result in civil penalties or other enforcement actions for both private and government entities, with public disclosure governed by 5 U.S.C. 552 and the aforementioned federal regulations.
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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
| ______ | ||
| TITLE | PHONE NUMBER |
ADDRESS CITY, STATE AND ZIP CODE
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