W900KK23R0005_Attach_31_CBID_III_Security_Self-Vetting_Form_20221104.docx

SECURITY SELF-VETTING FOR CONTRACTORS

To facilitate the security vetting procedures required to support your participation on FAR based contracts, please provide the following information and certify (sign) and date your responses.

1. Full Organization Name:

2. Organization Cage Code:

3. Is your organization registered in the System for Award Management (SAM) database (Yes or No)?

4. If you answered “No” to question #3, please provide information regarding any previous contracts or government work your organization has performed.

5. Does your organization have an active Facilities Clearance (FCL) (Yes or No)? If you answer “Yes,” what is the nature of the FCL (security level, possessing or non-possessing)?

6. Is your organization (or your subcontractors) foreign owned or under USA Foreign Owned, Controlled, or Influenced (FOCI) status (Yes or No)?

7. Is your organization in merger and/or purchasing discussions with a foreign company or a USA FOCI company (Yes or No)? No

8. If you answered “Yes” to question #6 or #7, please provide the following information on each foreign owned or under USA FOCI company.

a. Full Company Name:

b. Cage Code:

c. Identify Country or Origin:

I certify the information I have provided on behalf of my organization is accurate and up to date.

Security Self-Vetting Form Page 1 of 1

Source Selection Sensitive – See FAR 2.101 and 3.104

FOR OFFICIAL USE ONLY