ATTACHMENT_J.4._USFJ_Form_28.pdf

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USFJ FORM 28, 20180308(EF)

THIS FORM IS SUBJECT TO THE PRIVACY ACT OF 1974

PREVIOUS EDITIONS ARE OBSOLETE

CONTRACTING OFFICER'S DETERMINATIONS AND AUTHORIZED LOGISTICAL SUPPORT

(TO BE FILLED OUT BY CONTRACTING OFFICER)

REQUIRING ACTIVITY

NAME (Last, First, Middle)

GOV'T AUTHORITY POC

DODID, if applicable

DATE OF BIRTH

HOME ADDRESS

CITIZENSHIP

PASSPORT #/ EXPIRATION

COMPANY POC

COMPANY POC TELEPHONE

COMPANY POC EMAIL

GOV'T AUTH. POC PHONE

DATE OF REQUEST

GOV'T AUTH. POC EMAIL

CONTRACT PERFORMANCE END

CONTRACT PERFORMANCE START DATE

EMPLOYEE EMAIL

COMPANY (Full Name) /Prime or Subcontractor

ASSIGNED KO

CONTRACT ISSUING AGENCY

ASSIGNED KO TELEPHONE

ASSIGNED KO EMAIL

CONTRACT START DATE & END DATE

CONTRACT NUMBER/ TASK ORDER

CONTACT'S EMAIL

CONTACT'S TELEPHONE

IN-THEATER CONTACT

The contractor employee is essential to the mission of the United States armed forces and has a high degree of skill of knowledge for the accomplishment of mission requirements by fulfilling one of the following:

Acquiring the skill and knowledge through a process of higher education or specialized training and experience;

Identified by the United States armed forces as necessary in an emergent situation and will remain in Japan for less than 91 days to fulfill specialized duties;

Possessing a license or certification issued by a U.S. Federal Department or Agency, U.S. State, U.S. Territory, or the District of Columbia to perform his or her duties; or Possessing a security clearance recognized by the United States to perform his or her duties; or Specifically authorized by the Joint Committee (to include Article XIV contractors); or Employee

EMPLOYEE:

EMPLOYEE:

is a US Citizen is not a US Citizen is ordinarily resident in Japan is not ordinarily resident in Japan

NO

Contractor Acknowledgment Form Completed?

is is not entitled to SOFA status under Article 1(b) of the US-Japan SOFA.

USFJ LETTER OF AUTHORIZATION (LOA) NOT VALID WITHOUT PHOTO ID

YES

Adobe LiveCycle Designer Template Order Form 11.0.1.20130826.2.901444.899636

* Authorized Government Services does not necessarily mean that the Government provides these services to contractors on a non-reimbursable basis. For certain categories of authorized services, the contractor may be required to reimburse the government IAW applicable Federal, DOD or COCOM regulations/policies and/or the contract terms and conditions.

The indicated Authorized Government Services on this LOA are only applicable for the designated counties to be visited during the deployment; however, if the services vary between countries, the contracting officer shall specify which services may be authorized in each country. If the country to be visited has a Status of Forces Agreement (SOFA) in place that governs that categories of services to be authorized, then the terms of the SOFA take precedence over the terms of this LOA.

** Combatant Commander (CCDR) authorization is required IAW FAR Clauses 52.225-26 in order for a contractor to be authorized to carry a weapon.

*** Resuscitative/Emergency Care is the default level of care. Unless specifically negotiated in the contract, ALL medical care is reimbursable to the U.S. Government.

The government organization specified above, in its mission support capacity under the contract, authorizes the individual employee identified herein, to proceed to the location(s) listed for the designated deployment period set forth above. Upon completion of the mission, the employee will return to the point of origin.

AUTHORIZED GOVERNMENT SERVICES (LOGISTICAL SUPPORT)*

WEAPON**

None TRANSPORTATION (other than MILAIR)

MILAIR

EXCESS BAGGAGE

MILITARY BANKING

COMMISSARY

MILITARY EXCHANGE

MWR FACILITIES

MILITARY ISSUED EQUIPMENT

MILITARY ISSUED CLOTHING

Open mess (club) membership, as determined by each respective club;

Casually assistance (mortuary services) on a reimbursable basis.

Routine medical care on a reimbursable basis for U.S. citizens and emergency medical care on a reimbursable basis for non-U.S. citizens;

Dental care, limited to relief of emergencies on a reimbursable basis;

Department of Defense Dependent Schools on a space-available and tuition paying basis;

Issuance of U.S. Forces, Japan Vehicle Operator's Permit;

Issuance of vehicle license plates Laundry and dry cleaning

BILLETING

CAC

LOCAL ACCESS BADGE

DINING FACILITY (DFAC)

GOV'T FURNISHED MEALS

APO/FPO POSTAL SERVICES

DIPLOMATIC POST OFFICE

PRIMARY CARE***

OTHER (SEE REMARKS FIELD)

JAPAN SPECIFIC SERVICES /SUPPORT

LOA REMARKS

LOA REMARKS (CONT'D)

Contracting Officer Approval Signature:

Print Name:

Email:

Date:

Phone: