FOCI Form.pdf

FOREIGN OWNERSHIP, CONTROL OR INFLUENCE (FOCI) DETERMINATION DOCUMENTS (Feb 2006)

NOTICE: Section 2536 of title 10, United States Code, prohibits the award of a contract under a national security program to an entity controlled by a foreign government if it is necessary for that entity to be given access to information by a proscribed category of information in order to perform the contract unless a waiver is granted by the Secretary of Energy. In addition, a Facility Clearance and FOCI information are required when the contract or subcontract to be awarded is expected to require employees to have access authorizations.

NOTICE: Offerors who have either a Department of Defense or a Department of Energy Facility Clearance generally need not resubmit the following foreign ownership information unless specifically requested to do so. Instead, provide your DOE Facility Clearance code or your DoD assigned commercial and government entity (CAGE) code. If uncertain, consult the office which issued this solicitation.

(a)(1) The contract work anticipated by this solicitation will require access to classified information or special nuclear material. Such access will require a Facility Clearance for the Seller organization and access authorizations (security clearances) for Seller personnel working with the classified information or special nuclear material. To obtain a Facility Clearance the Offeror must submit a Certificate Pertaining to Foreign Interests, Standard Form 328, and all required supporting documents to form a complete Foreign Ownership, Control or Influence Package. Standard Form 328 is available at the Company’s Contracts web site http://home.ornl.gov/divisions/procurement/docindex.htm under the title Special Articles and Forms.

(2) Information submitted by the Offeror in response to the Standard Form 328 will be used solely for the purpose of evaluating foreign ownership, control or influence and will be treated by DOE, to the extent permitted by law, as business or financial information submitted in confidence.

(3) Following submission of a Standard Form 328 and prior to contract award, the Seller shall immediately submit to the Company written notification of any changes in the extent and nature of FOCI which could affect the Offeror’s answers to the questions in Standard Form 328. Following award of a contract, the Seller must immediately submit to the cognizant security office written notification of any changes in the extent and nature of FOCI which could affect the Offeror’s answers to the questions in Standard Form 328. Notice of changes in ownership or control which are required to be reported to the Securities and Exchange Commission, the Federal Trade Commission, or the Department of Justice must also be furnished concurrently to the cognizant security office.

(b) Definitions. (1) Foreign Interest means any of the following: (A) A foreign government, foreign government agency, or representative of a foreign government; (B) Any form of business enterprise or legal entity organized, chartered or incorporated under the laws of any country other than the Untied States or its possessions and trust territories; and (C) Any person who is not a citizen or national of the United States.

(2) Foreign Ownership, Control, or Influence (FOCI) means the situation where the degree of ownership, control, or influence over a contractor by a foreign interest is such that a reasonable basis exists for concluding that compromise of classified information or special nuclear material may result.

(c) Facility Clearance means an administrative determination that a facility is eligible to access, produce, use or store classified information, or special nuclear material. A Facility Clearance is based upon a determination that satisfactory safeguards and security measures are carried out for the activities being performed at the facility. It is DOE policy that all contractors and subcontractors requiring access authorizations be processed for a Facility Clearance at the level appropriate to the activities being performed under the contract. Approval for a Facility Clearance shall be based upon:

(1) A favorable foreign ownership, control, or influence (FOCI) determination based upon the Seller’s response to the ten questions in Standard Form 328 and any required, supporting data provided by the Seller;

(2) A contract or proposed contract containing the appropriate security clauses;

(3) Approved safeguards and security plans which describe protective measures appropriate to the activities being performed at the facility;

(4) An established Reporting Identification Symbol code for the Nuclear Materials Management and Safeguards

Reporting System if access to nuclear materials is involved;

(5) A survey conducted no more than 6 months before the Facility Clearance date, with a composite facility rating of satisfactory, if the facility is to possess classified matter or special nuclear material at its location;

(6) Appointment of a Facility Security Officer, who must possess or be in the process of obtaining an access authorization equivalent to the Facility Clearance; and, if applicable, appointment of a Materials Control and Accountability Representative; and

(7) Access authorizations for key management personnel who will be determined on a case-by-case basis, and must possess or be in the process of obtaining access authorizations equivalent to the level of the Facility Clearance.

(d) A Facility Clearance is required prior to the award of a contract requiring access to classified information and the granting of any access authorizations under a contract. Prior to award of a contract, the DOE must determine that award of the contract to the Offeror will not pose an undue risk to the common defense and security as a result of its access to classified information or special nuclear material in the performance of the contract. The Company or DOE may require the Offeror to submit such additional information as deemed pertinent to this determination.

(e) A Facility Clearance is required even for contracts that do not require the contractor’s corporate offices to receive, process, reproduce, store, transmit, or handle classified information or special nuclear material, but which require DOE access authorizations for the contractor’s employees to perform work at a DOE location. This type facility is identified as a non-possessing facility.

(f) Except as otherwise authorized in writing by the Company, the provisions of any resulting contract must require that the Seller insert provisions similar to the foregoing in all subcontracts and purchase orders. Any subcontractors requiring access authorizations for access to classified information or special nuclear material shall be directed to provide responses to the questions in Standard Form 328, Certificate Pertaining to Foreign Interests, directly to the Company.

INSTRUCTIONS FOR COMPLETION OF THE CERTIFICATE PERTAINING TO FOREIGN INTERESTS

IF THE OFFEROR/BIDDER/CONTRACTOR IS OWNED BY A PARENT ORGANIZATION(S), THE FOCI CERTIFICATE PERTAINING TO FOREIGN INTERESTS (SF-328) MUST BE ATTACHED FOR ALL TIER PARENTS, I.E., ULTIMATE PARENT AND ANY INTERVENING LEVELS OF OWNERSHIP. EACH CERTIFICATION MUST BE SIGNED AND DATED BY AN AUTHORIZED OFFICIAL OF THE RESPECTIVE ORGANIZATION, I.E., AN OFFICIAL IDENTIFIED IN YOUR ORGANIZATION'S ARTICLES OF INCORPORATION OR BY-LAWS AS RESPONSIBLE FOR MANAGING THE BUSINESS AFFAIRS OF THE ORGANIZATION, OR ANY OTHER EMPLOYEE, IDENTIFIED BY NAME OF THE ORGANIZATION IF DESIGNATED IN WRITING BY SUCH AN AUTHORIZED OFFICIAL AS HAVING BEEN DELEGATED AUTHORITY TO EXECUTE THE FOCI CERTIFICATE PERTAINING TO FOREIGN INTERESTS (SF-328) ON BEHALF OF

THE ORGANIZATION.

IF YOUR ORGANIZATION OWNS OTHER ENTITIES, CONSOLIDATED INFORMATION FOR ALL YOUR

WHOLLY-AND/OR MAJORITY-OWNED SUBSIDIARIES (FOREIGN AND DOMESTIC) MUST BE PROVIDED.

IF THE OFFEROR/BIDDER/CONTRACTOR IS A PUBLICLY TRADED COMPANY OR A SUBSIDIARY OF ANOTHER CORPORATION, THE CONTRACTOR AND ALL TIER PARENTS MUST SUBMIT THE FOLLOWING INFORMATION IN

ADDITION TO THE EXECUTED FOCI REPRESENTATIONS:

1. THE ULTIMATE PARENT MUST SUBMIT ITS MOST RECENT ANNUAL REPORT, MOST RECENT PROXY STATEMENT FOR ITS ANNUAL MEETING OF STOCKHOLDERS, AND ITS SECURITIES AND EXCHANGE

COMMISSION 10-K REPORT.

2. SUBSIDIARIES MUST SUBMIT SEPARATE CONSOLIDATED FINANCIAL INFORMATION FOR THEIR ORGANIZATION AND ALL THEIR WHOLLY AND/OR MAJORITY-OWNED SUBSIDIARIES AND AFFILIATES.

3. THE CONTRACTOR AND ALL TIER PARENTS MUST SUBMIT A LIST IDENTIFYING THEIR RESPECTIVE ORGANIZATION'S OFFICERS, DIRECTORS, AND EXECUTIVE PERSONNEL, TO INCLUDE THEIR NAMES;

SOCIAL SECURITY NUMBERS; CITIZENSHIP; TITLES OF ALL POSITIONS THEY HOLD WITHIN THE

ORGANIZATION; AND WHAT CLEARANCES, IF ANY, THEY POSSESS OR ARE IN THE PROCESS OF

OBTAINING AND IDENTIFICATION OF THE GOVERNMENT AGENCY(S) THAT GRANTED OR WILL BE

GRANTING THOSE CLEARANCES.

4. IF ANY POSITION IS VACANT, SO STATE.

IF THE OFFEROR/BIDDER/CONTRACTOR IS A PRIVATELY OWNED COMPANY, THE FOLLOWING INFORMATION

MUST BE PROVIDED IN ADDITION TO THE EXECUTED FOCI REPRESENTATIONS:

1. CONSOLIDATED FINANCIAL INFORMATION FOR THEIR ORGANIZATION AND ALL THEIR WHOLLY-AND/OR

MAJORITY-OWNED SUBSIDIARIES AND AFFILIATES.

2. THIS INFORMATION MUST BE PROVIDED BY THE APPROPRIATE OFFICIAL WITHIN THEIR ORGANIZATION, E.G., CHIEF FINANCIAL OFFICER, TREASURER.

3. A LIST IDENTIFYING THE ORGANIZATION'S OWNERS, OFFICERS, DIRECTORS, AND EXECUTIVE PERSONNEL, TO INCLUDE THEIR NAMES; SOCIAL SECURITY NUMBERS; CITIZENSHIP; TITLES OF ALL POSITIONS THEY HOLD WITHIN THE ORGANIZATION; AND WHAT CLEARANCES, IF ANY, THEY POSSESS OR ARE IN THE PROCESS OF OBTAINING AND IDENTIFICATION OF THE GOVERNMENT AGENCY(IES) THAT

GRANTED OR WILL BE GRANTING THOSE CLEARANCES. (ALL BLANKS AND COLUMNS MUST BE

ADDRESSED. IF NOT APPLICABLE (N/A), STATE N/A OR NONE.) IF ANY POSITION IS VACANT, SO STATE.

Question #1:

a. Do any foreign person(s), directly or indirectly, own or have beneficial ownership of 5% or more of the outstanding shares of any class of your organization's equity securities? If yes:

· Identify the percentage of any class of stock or other securities issued, which are owned by foreign persons, broken down by country. Include indirect ownership through one or more intermediate level(s) of subsidiaries. Indicate voting rights of each class of stock.

· Are there shareholder agreements? If yes, attach a copy(s), and if none, so state.

· Indicate whether a copy of SEC Schedule 13D/13G report has been received from any investor. If yes, attach a copy(s).

NOTE: Ownership of less than 5% should be included if the holder is entitled to control the appointment and tenure of any management position.

b. (for entities which do not issue stock): Has any foreign person directly or indirectly subscribed 5% or more of your organization's total/capital commitment? If yes:

· Identify the percentage of total capital commitment which is subscribed by foreign persons.

· Is there an agreement (s) with the subscriber (s)? If yes, attach a copy(ies), and if none, so state.

Question #2:

Does your organization directly, or indirectly through your subsidiaries and/or affiliates, own 10% or more of any foreign interest? If yes:

· Identify the foreign interest by name, country, percentage owned, and personnel who occupy management positions with the organizations.

· If there are personnel from your organization who occupy management positions with the foreign firm(s), identify the name(s), title, and extent of involvement in the operations of the organizations (to include access to classified information).

Question #3:

Do any non-U.S. citizens serve as members of your organization's board of directors (or similar governing body), officers, executive personnel, general partners, regents, trustees or senior management officials? If yes:

· Identify the foreign person(s) by name, title, citizenship, immigration status and clearance or exclusion status.

· Attach copies of applicable by-laws or articles of incorporation which describe the affected position(s).

However, if you have already provided such copies to the Cognizant Security Agency Industrial Security Representative, so state.

Question #4:

Does any foreign person(s) have the power, direct or indirect, to control the election, appointment, or tenure of members of your organization's board of directors (or similar governing body) or other management positions of your organization, or have the power to control or cause the direction of other decisions or activities of your organization? If yes:

Identify the foreign person(s) by name, title, citizenship, and all details concerning the control or influence.

Note: If any foreign person(s) have such power, this question shall be answered in the affirmative even if such power has not been exercised, and whether or not it is exercisable through ownership of your facility’s securities, if such power may be invoked by contractual arrangements or by other means.

Question #5:

Does your organization have any contracts, agreements, understandings, or arrangements with a foreign person(s)? If yes:

For each instance, provide the name of the foreign person, country, percentage of gross income derived, and nature of involvement, including:

· whether defense/nuclear related or not

· involvement with classified or export controlled technology

· compliance with export control requirements

Where the organization has a large number of involvements and where these involvements are not defense nuclear related and represent a small percentage of gross income, the explanation can be a generalized statement addressing the totals by country.

Note: We do not expect and will not require the contractor to ask every customer if he/she falls within the NISPOM definition of a foreign person. We will ask the contractor to provide ongoing security education to those individuals who negotiate and/or administer such agreements regarding their responsibilities to report agreements with a foreign person(s) to the best of their knowledge. The contractor will be certifying the response to this question to “the best of his/her knowledge” or “through his/her best efforts”.

Question #6:

Does your organization, whether as borrower, surety, guarantor or otherwise have any indebtedness, liabilities or obligations to a foreign person(s)? If yes:

· Provide your overall debt-to-equity ratio (in percentage).

· With respect to indebtedness or liability to a foreign person, indicate to whom indebted or liable, what collateral has been furnished or pledged, and any conditions or covenants of the loan agreement. If stock or assets have been furnished or pledged as collateral, provide a copy of the loan agreement or pertinent extracts thereof (to include procedures to be followed in the event of default).

· If any debentures are convertible, provide specifics.

· If loan payments are in default, provide details.

This question should be answered in the affirmative if the debt is with a U.S. entity that is owned or controlled either directly or indirectly by a foreign person. If unknown, so state.

Note: As stated above, we do not expect and will not require the contractor to ask every lender if he/she qualifies as a foreign person. We will ask the contractor to provide ongoing security education to those employees who handle lending arrangements regarding their responsibilities to report any such arrangements with a foreign person lender, to the best of their knowledge. The contractor will be certifying the response to this question as being to “the best of his/her knowledge ”or“ through his/her best efforts”.

Question #7:

During your last fiscal year, did your organization derive:

a. 5% or more of its total revenues or net income from any single foreign person?

b. In the aggregate 30% or more of its revenues or net income from foreign persons?

If yes to either part of the question:

· Provide overall percentage of income derived from foreign sources by country, nature of involvement, and type of services or products.

· Indicate if any single foreign source represents in excess of 5% or total revenues or net income.

· Indicate whether any classified information is involved.

· State whether facility is in compliance with applicable export control requirements.

Note: As previously stated, we do not expect and will not require the contractor to ask every customer if he/she qualifies as a foreign person. We will ask the contractor to provide ongoing security education to those employees who handle information about company revenues regarding their responsibility to report revenues derived from a foreign person(s) to the best of their knowledge. The contractor will be certifying the response to this question as being to “the best of his/her knowledge” or “through his/her best effort”.

Question #8:

Is 10% or more of your organization's securities held in "nominee shares," in "street names" or in some other method which does not disclose the beneficial owner? If yes:

· Identify each foreign institutional investor holding 10% or more of the voting stock by name and address and the percentage of stock held.

· Indicate whether any investor has attempted to, or has exerted any control or influence over appointments to management positions or influenced the policies of the organization.

· Include copies of SEC Schedule 13D/13G.

Question #9:

Do any of the members of your organization's board of directors (or similar governing body), officers, executive personnel, general partners, regent's, trustees or senior management officials hold any positions with, or serve as consultants for, any foreign person(s)? If yes:

· Provide the name, title, citizenship, immigration status and clearance or exclusion status on all such persons.

· Identify, by name and address, each foreign organization with which such persons serve and indicate the capacity in which they are serving.

· Include a Statement of Full Disclosure of Foreign Affiliations for every cleared individual who is a representative of a foreign interest

Note. We expect the contractor to be able to answer this question fully for those individuals holding such positions with his/her foreign subsidiaries and any foreign interests. However, we do not expect and will not require the contractor to ask every individual to ascertain if he/she is serving as a director, officer or manager of a foreign person. We will ask the contractor to provide ongoing security education to all key management personnel of their responsibilities to report serving as an interlocking director or in any other type of positions with a foreign person to the best of their knowledge. The contractor will be certifying the response to this question as being to "the best of his/her knowledge" or "through his/her best efforts".

Question #10:

Is there any other factor (s) that indicates or demonstrates a capability on the part of foreign persons to control or influence the operations or management of your organization? If yes:

· Describe the foreign involvement in detail, including why the involvement would not be reportable in the preceding questions.

DEFINITIONS FOR COMPLETION OF THE CERTIFICATE PERTAINING TO FOREIGN INTERESTS

Affiliate - Any entity effectively owned or controlled by another entity.

Beneficial Owner - The true owner of a security who may, for convenience, be recorded under the name of a nominee. Such ownership entitles the owner to the power to vote or direct the voting of a security or to impose or direct the disposition of a security.

Bond - A certificate which is evidence of a debt in which the issuer promises to repay a specific amount of money to the bondholder, plus a certain amount of interest, within a fixed period of time.

Convertible Debentures - Bonds which the holder can exchange for shares of voting stock.

Covenant - A detailed clause in a lending agreement designed to protect the lender.

Debenture - A general debt unsecured by a pledge of any specific piece of property. Like any other general creditor claims, a debenture is secured by any property not otherwise pledged.

Debt-to-Equity Ratio - Total liabilities divided by total shareholders' equity (total assets minus total liabilities of a corporation;

also called stockholders' equity, equity, and net worth). This shows to what extent owners' equity can cushion creditors’ claims in the event of liquidation.

Equity Security - An ownership interest in a company, most often taking the form of corporate stock.

Foreign Interest - Any foreign government, agency of a foreign government, or representative of a foreign government; any form of business enterprise or legal entity organized, chartered or incorporated under the laws of any country other than the U.S. or its possessions and trust territories, and any person who is not a citizen or national of the United States.

Foreign Person - Any foreign interest and any U.S. person effectively owned or controlled by a foreign interest.

Guarantor - One who makes the guaranty (an agreement or promise to answer for the debt, default or miscarriage of another).

Immigration Status - Legal basis for a non-U.S. citizen's residence in the United States (e.g., work visa, admission for permanent residence). Note: Immigration and Naturalization Service Form I-9 is an excellent source for this information.

Joint Venture - A partnership or cooperative agreement between two or more persons or firms, usually restricted to a single specific undertaking. Normally the undertaking is of short duration, such as for the design and construction of a dam.

Liability - Claim on the assets of a company or individual.

Licensing Agreement - A permit granted by one business to another which permits duplication of processes and production of similar items.

Management Positions - For the purposes of the questions on this form, management positions shall include owners, officers, directors, partners, regents, trustees, senior management officials, other executive personnel and the facility security.

Nominee Share - A share of stock or registered bond certificate which has been registered in a name other than the actual owner.

Proxy - One who acts for another. Also, the document by which such a representative is authorized to act.

Representative of a Foreign Interest (RFI ) - A citizen or national of the U.S., who is acting as a representative of a foreign interest (see Foreign Interest).

S.E.C. Schedule 13D - This schedule discloses beneficial ownership of certain registered equity securities. Any person or group of persons who acquire a beneficial ownership of more than 5 percent of a class of registered equity securities of certain issuers must file a Schedule 13D reporting such acquisition with certain other information.

S.E.C. Schedule 13G - This schedule is a much abbreviated version of Schedule 13D that is only available for use by a limited category of "persons” (such as banks, broker/dealers, and insurance companies) and even then only when the securities were acquired in the ordinary course of business- and not with the purpose or effect of changing or influencing the control of the issuer.

Sales Agreement - An agreement between two parties for the sale of goods or services on a continuing basis.

Stock Option - An option is the right to buy or sell at some point in the future.

Street Name - The common practice of registering publicly traded securities in the name of one or more brokerage firms.

Subordinated Debenture - A bond having a claim on assets only after the senior debt has been paid off in the event of liquidation.

Surety - One who is immediately liable for the debt of another if that other person or entity fails to pay.

Total Capital Commitment - The sum of money and other property an enterprise uses in transacting its business.

U.S. Person - Any form of business enterprise or entity organized, chartered or incorporated under the laws of the United States or its possessions and trust territories and any person who is a citizen or national of the United States.

List ALL Owners, Officers, Directors, and Executive Personnel (OODEPs) 1.2 Page of ____

Company’s Current Legal Name, Address, and Phone Number Other names used (e.g., doing business as): Date Submitted:

of Company’s Principal Executive Offices:

Tax Identification No.

Date Company was Incorporated:

State of Incorporation:

(Must provide any name or address change of the Company’s principal executive office and date(s) of change during past 10 years on the Attachment page.)

Organization Status:

Corporation Sole Proprietorship Partnership:

General Limited

Other:

Stock Ownership:

Privately-Owned Publicly-Traded Subsidiary of:

NAME

First Name, Initial, Last Name

POSITION TITLES IF OWNER,

% OF OWNERSHIP 2

SSN CLEARANCE HELD AND/OR

BEING OBTAINED AND

ISSUING AGENCY

CITIZENSHIP

Facility Security Officer 1 The above information, i.e., name, titles, etc., must be provided for the following: (a) the proprietor of a sole proprietorship; (b) all individuals managing the business affairs of a corporation. In most cases, these individuals are identified in the Articles of Incorporation or By-Laws and include the Board of Directors, President, Secretary, and Treasurer; (c) the General Partner(s) of a Limited Partnership; and (d) all partners of a General Partnership.

2 In addition, privately-held entities must provide the above information, i.e., name, titles, etc., for all owners, and also provide the percentage of issued stock/shares held by each owner List certified correct by:

Typed or Printed Name and Signature Title Date

COMPANY’S PRINCIPAL EXECUTIVE OFFICE NAME/ADDRESS CHANGE

Company Name/Address Change: Date of Change:

FOCI DATA SHEET

COMPANY NAME:

Listed below are documents required to complete a FOCI Determination.

FOCI Determination Documents common to all Business Structures

OODEP LIST

RFI STATEMENT

SF-328

WEB PAGE ADDRESS (if applicable)

Additional documents required to be included for a PUBLICLY TRADED CORPORATION

ARTICLES OF INCORPORATION

SEC 10K REPORT

PROXY STATEMENT

SEC SCHEDULES 13D & 13G

CORPORATE BY-LAWS

IRS FORM 5471

ANNUAL REPORT WITH FINANCIAL INFORMATION

Additional documents required to be included for a PRIVATELY OWNED CORPORATION

ARTICLES OF INCORPORATION

CORPORATE BY-LAWS _

IRS FORM 5471 (IF APPLICABLE)

ANNUAL REPORT WITH FINANCIAL INFORMATION (OR)

AUDITED FINANCIAL INFORMATION IN LIEU OF ANNUAL REPORT

(IF UNAUDITED, SUBMIT A CERTIFICATION ATTESTING TO THE

UNAVAILABILITY OF AUDITED INFORMATION)

Additional documents required for a PARTNERSHIP

PARTNERSHIP AGREEMENT

SEC 10K REPORT

PROXY STATEMENT

SEC SCHEDULES 13D & 13G

IRS FORMS 5471 & 1065

LATEST ANNUAL REPORT WITH FINANCIAL INFORMATION (OR)

AUDITED FINANCIAL INFORMATION IN LIEU OF ANNUAL REPORT

(IF UNAUDITED, SUBMIT A CERTIFICATION ATTESTING TO THE

UNAVAILABILITY OF AUDITED INFORMATION)

MOST CURRENT BOARD MEETING MINUTES IDENTIFYING

EXECUTIVE APPOINTMENTS/CHANGES

Additional documents required for a PROPRIETORSHIP

TAX ID NO./STATE REGISTRATION CERTIFICATE

IRS FORM 1040

ANNUAL REPORT OR AUDITED FINANCIAL INFORMATION FOR MOST

RECENT FISCAL YEAR (IF AUDITED REPORT IS NOT AVAILABLE

CFO/TREASURER MUST SIGN AND DATE THE FINANCIAL STATEMENT

CERTIFYING THAT IT IS CURRENT AND CORRECT)

IF COMMUNITY PROPERTY STATE (AZ, CA, ID, LA, NV, NM, TX, WA,

WI) SPOUSAL INFORMATION IS ALSO REQUESTED. IF SUBJECT IS

SINGLE PLEASE SO STATE.

Additional documents required for a LIMITED LIABILITY CORPORATION

CERTIFICATE OF ORGANIZATION

OPERATING AGREEMENT

AUDITED FINANCIAL INFORMATION FOR MOST RECENT FISCAL YEAR

(IF UNAUDITED THE CFO/TREASURER MUST SIGN AND DATE THE

FINANCIAL STATEMENT CERTIFYING THAT IT IS CURRENT AND

CORRECT)

Additional documents required for a COLLEGE/UNIVERSITY

UNIVERSITY CHARTER

LATEST ANNUAL REPORT

MOST CURRENT BOARD MEETING MINUTES IDENTIFYING

EXECUTIVE APPOINTMENTS/CHANGES

SAMPLE FORMAT

REPRESENTATIVE FOR FOREIGN INTEREST STATEMENT

This form is to be initially submitted, as part of the FOCI package, by the contractor or subcontractor. The form should be completed and executed by each employee who holds a position with a foreign interest and who possesses or is being processed for a DOE security clearance who becomes an RFI or whose status as an RFI changes in a manager that would make him/her ineligible for a security clearance.)

Name and address of the foreign firm:

Nature of business of foreign firm:

Details of ownership of foreign firm:

The specific relationship between the foreign firm and the United States firm:

Percentage of time devoted to foreign firm:

Summary of duties with the United State firm. Provide detailed information as well as title of position:

Summary of duties with the foreign firm. Provide detailed information as well as title of position:

Have you ever registered as an Agent of a foreign government as detailed in 18 U.S.C. 219? If so, provide details:

Communist affiliation; if none, so state:

CERTIFICATION

I recognize my special responsibility to protect classified information from disclosure to any unauthorized person, foreign or domestic.

Typed or Printed Name:

Full Name: Date:

(Signature)

SSN:

Facility: