SP330023R5001 Attachment J.12 - DD254.pdf
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- Solicitation number
- SP330023R5001
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Defense Logistics Agency Distribution
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DRAFT
SAMPLE
PREVIOUS EDITION IS OBSOLETE.
Page of
DD FORM 254, APR 2018
NEEDS DD67
DEPARTMENT OF DEFENSE
CONTRACT SECURITY CLASSIFICATION SPECIFICATION
(The requirements of the National Industrial Security Program (NISP) apply to all security aspects of this effort involving classified information.)
OMB No. 0704-0567 OMB approval expires:
May 31, 2022 The public reporting burden for this collection of information, 0704-0567, is estimated to average 70 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing the burden, to the Department of Defense, Washington Headquarters Services, at whs.mc-alex.esd.mbx.dd-dod-information-collections@mail.mil. Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number.
RETURN COMPLETED FORM AS DIRECTED IN THE INSTRUCTIONS.
1. CLEARANCE AND SAFEGUARDING
2. THIS SPECIFICATION IS FOR: (X and complete as applicable.)
3. THIS SPECIFICATION IS: (X and complete as applicable.)
a. ORIGINAL (Complete date in all cases.)
b. REVISED (Supersedes all previous specifications.)
4. IS THIS A FOLLOW-ON CONTRACT?
If yes, complete the following:
Classified material received or generated under
5. IS THIS A FINAL DD FORM 254?
If yes, complete the following:
6. CONTRACTOR (Include Commercial and Government Entity (CAGE) Code)
7. SUBCONTRACTOR(S) (Click button if you choose to add or list the subcontractors -- but will still require a separate DD Form 254 issued by a prime contractor to each subcontractor)
8. ACTUAL PERFORMANCE (Click button to add more locations.)
10. CONTRACTOR WILL REQUIRE ACCESS TO: (X all that apply. Provide details in Blocks 13 or 14 as set forth in the instructions.)
e. NATIONAL INTELLIGENCE INFORMATION:
11. IN PERFORMING THIS CONTRACT, THE CONTRACTOR WILL: (X all that apply. See instructions. Provide details in Blocks 13 or 14 as set forth in the instructions.)
12. PUBLIC RELEASE
Any information (classified or unclassified) pertaining to this contract shall not be released for public dissemination except as provided by the National Industrial Security Program Operating Manual (NISPOM) or unless it has been approved for public release by appropriate U.S. Government authority. Proposed public releases shall be submitted for review and approval prior to release to the appropriate government approval authority identified here with at least office and phone contact information and if available, an e-mail address. (See instructions)
13. SECURITY GUIDANCE
The security classification guidance for classified information needed for this effort is identified below. If any difficulty is encountered in applying this guidance or if any other contributing factor indicates a need for changes in this guidance, the contractor is authorized and encouraged to provide recommended changes; to challenge the guidance or the classification assigned to any information or material furnished or generated under this contract; and to submit any questions for interpretation of this guidance to the official identified below. Pending final decision, the information involved shall be handled and protected at the highest level of classification assigned or recommended.
(Fill in as appropriate for the classified effort. Attach, or forward under separate correspondence, any documents/guides/extracts referenced herein. The field will expand as text is added. When removing any expanded text area, use delete key or backspace key, then click out of the text field for it to shrink after the text has been deleted. Also allows for up to 6 internal reviewers to digitally sign. See instructions for additional guidance or use of the fillable PDF.)
List of Attachments (All Files Must be attached Prior to Signing, i.e., for any digital signature on the form)
14. ADDITIONAL SECURITY REQUIREMENTS
Requirements, in addition to NISPOM requirements for classified information, are established for this contract.
If Yes, identify the pertinent contractual clauses in the contract document itself, or provide an appropriate statement which identifies the additional requirements. Provide a copy of the requirements to the CSO. The field will expand as text is added or you can also use item 13. When removing any expanded text area, use delete key or backspace key, then click out of the text field for it to shrink after the text has been deleted. (See instructions for additional guidance or use of the fillable PDF.)
15. INSPECTIONS
Elements of this contract are outside the inspection responsibility of the CSO.
If Yes, explain and identify specific areas and government activity responsible for inspections. The field will expand as text is added or you can also use item 13. When removing any expanded text area, use delete key or backspace key, then click out of the text field for it to shrink after the text has been deleted. (See instructions for additional guidance or use of the fillable PDF.)
16. GOVERNMENT CONTRACTING ACTIVITY (GCA) AND POINT OF CONTACT (POC)
17. CERTIFICATION AND SIGNATURES
Security requirements stated herein are complete and adequate for safeguarding the classified information to be released or generated under this classified effort. All questions shall be referred to the official named below. Upon digitally signing Item 17h, no changes can be made as the form will be locked.
18. REQUIRED DISTRIBUTION BY THE CERTIFYING OFFICIAL
9.0.0.2.20120627.2.874785 DD 254, "DoD Contract Security Classification Specification" Hide Attachment Bar
| CurrentPage: |
| PageCount: |
| Select classification from drop-down list.: Unclassified |
| SerialNum: |
| a. Facility clearance level. Select one.: 2 |
| b. Level of safeguarding for classified information/material required at contractor facility. Select one.: 4 |
| Select for "original.": 0 |
| Select for "original.": 1 |
| Enter prime contract number.: |
| Select for "revised.": 0 |
| Select for "revised.": 0 |
| Enter subcontract number.: |
| Select for "final.": 1 |
| Select for "final.": 0 |
| Enter solicitation or other number.: SP330023R5001 |
| Enter due date in format YYYYMMDD.: |
| Enter date in format YYYYMMDD.: 20220823 |
| Enter revision number.: |
| Enter date in format YYYYMMDD.: |
| Enter final specification.: |
| Enter date in format YYYYMMDD.: |
| Select for "no.": 0 |
| Select for "no.": 1 |
| Select for "no.": 0 |
| Select for "no.": 1 |
| Select for "yes.": 1 |
| Select for "yes.": 0 |
| Select for "yes.": 1 |
| Select for "yes.": 0 |
| Enter preceding contract number.: SP330019D5001 |
| Enter contractor's request date in format YYYYMMDD.: |
| Enter period.: |
| Enter typed name of certifying official (last, first, middle initial).: Jada A. Weaver |
| Enter CAGE code of the prime contractor.: 6WHH3 |
| Enter CAGE code of the prime contractor.: 7KJG7 |
| Enter cognizant security office(s) (Name, Address, ZIP Code, Telephone required; Email Address optional).: Pacific Region, DIS |
Southern Sector 3605 Long Beach Blvd, Suite 405 Long Beach, CA 90807-4013
| Select to add row to locations.: |
| Select to remove last row from locations.: |
| Select to delete all signatures.: |
| Enter location(s).: DLA Distribution Guam, Marianas (DDGM) |
Building 2118, Receiving Section Sumay Drive Santa Rita, Guam 96915
| Enter general unclassified description of this procurement.: Government-Owned Contractor-Operated distribution services at DLA Distribution Guam. Contractor will receive, store, and issue materiel within a government owned facility. Materiel received, stored, and issued includes classified items. |
| Select for "a. CONTRACTOR.": 0 |
| Select for "a. CONTRACTOR.": 1 |
| Select for "a. CONTRACTOR.": 1 |
| Select for "f. OTHER AS NECESSARY.": 0 |
| Select for "f. OTHER AS NECESSARY.": 0 |
| Select for "f. OTHER AS NECESSARY.": 1 |
| Select for "b. SUBCONTRACTOR.": 1 |
| Select for "b. SUBCONTRACTOR.": 0 |
| Select for "b. SUBCONTRACTOR.": 0 |
| Select for "g. BE AUTHORIZED TO USE THE SERVICES OF DEFENSE TECHNICAL INFORMATION CENTER (DTIC) OR OTHER SECONDARY DISTRIBUTION CENTER.": 0 |
| Select for "g. BE AUTHORIZED TO USE THE SERVICES OF DEFENSE TECHNICAL INFORMATION CENTER (DTIC) OR OTHER SECONDARY DISTRIBUTION CENTER.": 0 |
| Select for "c. COGNIZANT SECURITY OFFICE FOR PRIME AND SUBCONTRACTOR.": 0 |
| Select for "c. COGNIZANT SECURITY OFFICE FOR PRIME AND SUBCONTRACTOR.": 0 |
| Select for "c. COGNIZANT SECURITY OFFICE FOR PRIME AND SUBCONTRACTOR.": 1 |
| Select for "h. REQUIRE A COMSEC ACCOUNT.": 0 |
| Select for "h. REQUIRE A COMSEC ACCOUNT.": 0 |
| Select for "d. U.S. ACTIVITY RESPONSIBLE FOR OVERSEAS SECURITY ADMINISTRATION.": 1 |
| Select for "d. U.S. ACTIVITY RESPONSIBLE FOR OVERSEAS SECURITY ADMINISTRATION.": 0 |
| Select for "d. U.S. ACTIVITY RESPONSIBLE FOR OVERSEAS SECURITY ADMINISTRATION.": 0 |
| Select for "i. HAVE A TEMPEST REQUIREMENT.": 0 |
| Select for "i. HAVE A TEMPEST REQUIREMENT.": 0 |
| Select for "e. NATIONAL INTELLIGENCE INFORMATION: - (1) Sensitive Compartmented Information (SCI).": 0 |
| Select for "e. NATIONAL INTELLIGENCE INFORMATION: - (2) Non-SCI.": 0 |
| Select for "j. HAVE OPERATIONS SECURITY (OPSEC) REQUIREMENTS.": 1 |
| Select for "j. HAVE OPERATIONS SECURITY (OPSEC) REQUIREMENTS.": 1 |
| Select for "k. BE AUTHORIZED TO USE DEFENSE COURIER SERVICE.": 0 |
| Select for "k. BE AUTHORIZED TO USE DEFENSE COURIER SERVICE.": 0 |
| Enter infomration for "other.": DLA Industrial Security Manager |
| Select for "e. ADMINISTRATIVE CONTRACTING OFFICER.": 0 |
| Select for "e. ADMINISTRATIVE CONTRACTING OFFICER.": 1 |
| Select for "l. RECEIVE, STORE, OR GENERATE CONTROLLED UNCLASSIFIED INFORMATION (CUI). .": 1 |
| Select for "m.OTHER.": 0 |
| Select for "direct.": 0 |
| Select for ": 1 |
| Enter specification for "through".: Contract Officer (CO), DLA Distribution, J Ave., Bldg 430, New Cumberland, PA 17070 |
| Enter public release authority.: Public Affairs Officer, DLA Distribution, J Ave., Bldg 430, New Cumberland, PA 17070 |
| Select to add signature.: |
| Select to remove last signature.: |
| text: |
See attached continuation pages.
| Click on this button to attach a file(s).: |
| rep: David P. Firlik |
| Enter signature.: |
| Explain and identify specific areas and government activity responsible for inspections.: See Reference Items 10b, 10d, 10j, 11a, 11j, and 11l. |
| Enter GCA name.: DLA Distribution Guam Marianas |
| Enter AAC of the contracting office.: 6WHH3 |
| Enter AAC of the contracting office.: SP3300 |
| Enter address (include zip code).: DLA Distribution Guam, Marianas (DDGM) |
Building 2118, Receiving Section Sumay Drive Santa Rita, Guam 96915 Enter address (include zip code).: DLA Distribution Acquisition Operations (J7) 5430 Mifflin Avenue, Suite 3102A New Cumberland, PA 17070-5008
| Enter POC name.: Daniel L. Francisco |
| Enter telephone number (include area code).: 6713394530 |
| Enter telephone number (include area code).: 7177704378 |
| Enter email address.: jada.weaver@dla.mil |
| Enter title.: Contracting Officer |
| Enter the datesigned in format YYYYMMDD.: 20230411 |
File details come from the government source that posted it. Updated .