Sensitive_Security_Information_Acknowledgement_Form.docx

DOCX document 20 KB Posted

Attached to
Employee Wellness Platform
Solicitation number
RFP PS-27-0485
Issued by
Maricopa County, Phoenix City, Arizona

About this file

This document is a Sensitive Security Information Acknowledgement Form from the City of Phoenix Aviation Department, applicable to a state and local contract opportunity in Arizona. The form is a template designed to be completed for specific projects involving sensitive security information controlled under 49 C.F.R. Parts 15 and 1520. Signatories acknowledge receipt of restricted documents that may only be disclosed to individuals with a demonstrated need to know, and agree to comply with federal regulations governing the handling and destruction of such materials. The form requires completion of document titles, project names, contract end dates, and authorized representative information before execution.

The form serves as a compliance mechanism requiring authorized company representatives to certify understanding of restrictions on information disclosure and to commit to destroying all sensitive security documents upon either completion of their business need or by a specified contract end date, whichever occurs first. Unauthorized release of the controlled information may result in civil penalties or other legal action. This acknowledgement applies across both private sector offerors and U.S. government agencies, with public disclosure further governed by the Freedom of Information Act and applicable Code of Federal Regulations provisions.

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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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