Attachment_2_Facility_Clearance_Sponsorship_Form.pdf

FACILITY CLEARANCE (FCL) REQUEST

Date of Request: ___________ Defense Security Service (DSS) ATTN: Facility Clearance Branch (FCB) 27130 Telegraph Road Quantico, VA 22134

Email complete FCL sponsorship requests to: occ.facilities@dss.mil

Detailed instructions for submitting an FCL sponsorship request are available at http://www.dss.mil/isp/fac_clear/fac_clear.html in the “sample sponsorship letter” document.

Please contact FCB at occ.facilities@dss.mil or 571-305-6619 if you have questions.

SPONSORED FACILITY INFORMATION

Please process the following facility for an FCL:

1. Legal Name of Facility

2. CAGE Code

Note: A CAGE code is required before an FCL can be issued. Please visit www.sam.gov to obtain a CAGE code.

3. Physical Street Address (no P.O. Boxes) City, State, and Zip Code

4. Company Website

5. State and date of Incorporation/Organization

6. Business Structure (Corporation, LLC, etc.)

7. Is the company a Joint Venture (JV)? Yes No

8. Is the Facility located on a Government installation?

Yes (sponsorship request must include a signed letter from the Commander or Head of the installation) No

9. Does the Facility hold an FCL with another Government agency besides DSS?

Yes (must answer 9a) No

9a. If yes, please specify which Government agency and level of the FCL:

10. Sponsored Facility’s Primary Type of Business

11. Sponsored Facility’s Principal Product/Service

DSS FCL SPONSORSHIP LETTER, OCTOBER 2015

CONTRACT INFORMATION

Note: Justification for the FCL must be included with your request and must validate the FCL and Safeguarding levels requested. The most common form of justification is a DD Form 254 issued from the Sponsor to the Sponsored Facility. For assistance with completing the DD254, please visit https://stepp.dss.mil/courseware/dd254/ddform254fillable.pdf

12. Intended Facility Security Officer (FSO) (must be knowledgeable of FCL sponsorship request) FSO Legal Name (do not use nicknames) FSO Email FSO Phone FSO Address (if different than Facility address)

Note: It is highly recommended that the person listed as FSO be the person who is actually intended to be the FSO. The initial contacts during the FCL process are designed to prepare the FSO to successfully complete the FCL process and switching FSOs during the process or immediately after the company is cleared will put the company behind.

13. Alternate Point of Contact (POC) at Sponsored Facility Alternate POC Legal Name Alternate POC Title Alternate POC Email Alternate POC Phone

14. This request is based on a bona fide procurement requirement to access classified information for work on the following contract number(s):

15. Level of Clearance Required

16. Level of Safeguarding Required (at Sponsored Facility)

17. Total number of employees at Sponsored Facility (approx.)

18. Does the Sponsored Facility currently have two or more employees who will work on the classified contract?

Yes No (must answer 18a.)

18a. If an FCL is being request for a one-person company or only one person will work on the classified portion of the contract, explain why the person cannot work as a consultant in accordance with Industrial Security Letter (ISL) 2006-02, #12, available at

19. Primary Industrial Base Technology category applicable to this contract (see http://www.dss.mil/documents/ci/2015_DSS _Trend_Report.pdf, pg. 48-50 for additional information) If multiple categories are applicable, please list them here:

20. Is this sponsorship request based on a contract that is in a pre-award stage?

Yes (must answer 20a.) No

20a. If yes, is access to classified information required during the pre-award stage?

Yes No (The company cannot be processed for an FCL at this time. See note.)

Note: A company must have a valid procurement need to access classified information at the time of FCL sponsorship. If the sponsored company is in the pre-award stage, access to classified information must be required during the pre-award stage in order for DSS to accept this request and this should be clearly indicated on the request. For a subcontract, Government Contracting Activity (GCA) written approval must be provided to confirm that access to classified information is required for the subcontractor during the pre-award stage.

21. Is access to classified information required in performance of this contract? Yes No

22. Provide a brief, unclassified description of the type of information, material, or systems the sponsored company will require access to that is classified at the FCL level being requested in performance of this contract:

NOTE: The processing of investigations for purposes other than access to classified information related to a classified contract is the responsibility of the GCA. The GCA is responsible for funding, submitting, and managing these types of investigations which are outside the National Industrial Security Program (NISP). Examples of investigations for other than access to classified information include but are not limited to, base access, suitability for logical access to unclassified information systems, positions of trust, and unclassified information systems administrator access (IT Levels).

Companies that do not require access to classified information are not eligible for an FCL. If an FCL is being requested for a service contract in which access to classified information cannot be precluded by implementing basic security procedures, a compelling need letter signed by the GCA must be included with the sponsorship package. Please see ISL 2006-02, #6 for more information .

SPONSOR INFORMATION

25. Sponsoring GCA or Cleared Defense Contractor

23. Is this request based on a subcontract issued to the Sponsored Facility? Yes (must answer 23a.) No

23a. If yes, will CNWDI, SCI or non-SCI Intelligence, COMSEC, or NATO information be disclosed to the subcontractor/Sponsored Facility? This must be supported in the justification (e.g. section 10a, 10c, 10e1/10e2, and 10g of the DD254). Yes* No

*If this is a subcontract that will involve the disclosure of CNWDI, Intelligence, COMSEC, or NATO information to the subcontractor, you must obtain GCA concurrence to share this information with the Sponsored Facility in accordance with NISP OM requirements. A copy of the concurrence must be included with your sponsorship request. If concurrence is not provided, the request will be rejected.

24. GCA POC (must be knowledgeable of program requirements) Program-specific GCA POC Name Program-specific GCA POC Title Program-specific GCA POC Email Program-specific GCA POC Phone

CAGE Code (if applicable) Company Name (if applicable) POC Name POC Title POC Email POC Phone POC Signature