(12-05)Replaces DOE F 470.1 (05-05

> contract security classification specification (CSCS) COMPLETION Guide
>
> **Use this Form For Procurement Contracts and No Fee Agreements
> Only.**

-   The CSCS form is required for all Contracts and/or Agreements
    requiring personnel clearances and must be initiated by Line
    Requester: (**1**) "Original" - First time Contract Registration;
    (**2**) "Revised" - Modification of contract (contract extension,
    classification change, are most common),"; (**3**) "Final" -
    Completion/Termination of Contract.

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-   Requester, forward completed CSCS form (DOE F 470.1), to the
    *Security POC in SNL/NM or SNL/CA respectively.*

    -   In SNL/NM, forward to **Viki Cox**, Department 4234, MS-0852.

    -   In SNL/CA, forward to **Meaghan Shay** Department 8511-1,
        MS-9113.

**[INSTRUCTIONS FOR THE CSCS FORM]{.underline}**

**If the work activity is related to a Special Access program (SAP),
STOP and contact Donna Roth at 284-6250.**

> **Block 1 - [CSCS Number:]{.underline}** ***(**The Security POC in
> SNL/NM or SNL/CA respectively will complete this block**)***
>
> **Block 2 - [Previous CSCS Number:]{.underline}** ***(**The Security
> POC in SNL/NM or SNL/CA respectively will complete this block**)***
>
> **Block 3 - [Reason for Action:]{.underline}** ***(**The Security POC
> in SNL/NM or SNL/CA respectively will complete this block**)***
>
> **Block 4 - This Specification Is For:** Information relating to this
> Purchase Requisition(PR)/contract.
>
> a\. **Contract or Other Number Block --** Identify whether the
> security activity is a Contract or other number, or a Solicitation.
> Also in this section, identify "type of contract" examples are:
> Regular Procurement Contract, As Ordered Agreement (AOA), Blanket
> Purchase Agreement BPA, Contract Purchase Agreement CPA, No Fee
> Agreement (NFA), etc... This number must be a unique number and
> different from the Prime Contract Number. An agreement processed
> through an organization other than Procurement must also have a unique
> number. For classified "Solicitations" same process applies.

b.  To maintain the integrity of DOE's Safeguard and Security
    Information Management System (SSIMS) database, a **Subcontract
    Number** between Sandia National Laboratories and the
    Contractor/facility or contract numbers between subcontractor
    facilities must be entered here and must be unique from one another.

c.  Prime Contract Number between Sandia National Laboratories and the
    U.S. Department of Energy or in cases of subcontracting, the Prime
    Subcontractors contract #.

> **Block 5 - [Specification Is.]{.underline}** ***(**The Security POC
> in SNL/NM or SNL/CA respectively will complete this block**)**.*
> **[Original]{.underline}:** Date the contract award was reported to
> DOE/NNSA. **[Revised]{.underline}**: Date when contract revision was
> reported to DOE/NNSA. **[Final]{.underline}**: Date contracts
> conclusion/termination was reported to DOE/NNSA.
>
> **Block 6 - [General Identification of This
> Procurement.]{.underline}** Brief, concise, unclassified Statement of
> Work (SOW), to be performed under contract/Agreement. (Should be an
> excerpt of the actual SOW)
>
> **Blocks 7a, 8a, 9a - [Facility/Cage Code.]{.underline}** Facility
> code for Subcontractor's facility, Contractor's facility and actual
> place of performance facility. ***(**The Security POC in SNL/NM or
> SNL/CA respectively will complete this block**)***
>
> **Block 7b - [Subcontractor Name, Address, and Zip
> Code.]{.underline}** Contractor Legal Name, DBA (Doing Business As)
> and address of Subcontractor facility that the Prime Contractor
> subcontracted work to ([separate CSCS forms must be completed for each
> Subcontractor).]{.underline}
>
> **Block 8b - [Contractor Name, Address, and Zip Code.]{.underline}**
> Contractor Legal Name, DBA (Doing Business As) and address of
> Contractor/facility, which will be awarded the contract. Sandia
> address will be used unless the contract is being subcontracted**.**
>
> **Block 9b:**

-   **(DOE Facilities) - [Actual Performance Location.]{.underline}**
    Sandia address will be the default unless the Contractor has been
    approved as a possessing facility. *Requester or Sandia Contracting
    Representative (SCR) is to update this block as required. NOTE: If a
    site other than Sandia/NM is the place of performance, this section
    must be modified accordingly.*

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-   **(Non-DOE Facilities) - [Actual Performance
    Location.]{.underline}** This block is to be left blank unless a
    non-DOE facility will be utilized as an actual place of performance
    for classified work (must be approved by DOE). *Requester or Sandia
    Contracting Representative (SCR) is to update this block as
    required*

> *.*
>
> **Blocks 7c, 8c, 9c - [Cognizant Security Office.]{.underline}**
> Primary DOE/NNSA Office responsible for FOCI updates. ***(**The
> Security POC in SNL/NM or SNL/CA respectively will complete this
> block**)***
>
> **Blocks 10 a-c - [Clearance and Storage.]{.underline}** Options for
> 10 "a," "b," and "c" are: Levels: TS = Top Secret; S=Secret;
> C=Confidential and U=Unclassified. Categories are: RD=Restricted Data;
> FRD=Formerly Restricted Data; NSI=National Security Information. The
> available combinations are: **TSRD, TSFRD, TSNSI, SRD, SFRD, SNSI,
> CRD, CFRD, CNSI and U.** Check only the highest level/category
> combination required. If you are requesting SCI clearance, it must
> have TS level associated with it as required by Sandia's Top Secret
> Program Coordinator.
>
> (**10a**) -- Classification of Matter to be Accessed: Refers to
> highest level of clearance required for the contract; (**10b**) -
> Level of Storage Required at Contractor Site: **Note:** Anything other
> than "U" in this section requires DOE/NNSA approval and/or survey);
> (**10c**) - Level of Storage for this Contract**. (10d) -** Access
> Authorization: Q or L Clearance.
>
> Special Note:

-   If Sandia is the Designated Responsible Office (DRO) for the
    contractor facility, the facilities Key Management Personnel (KMP)
    must be cleared to their highest level contract with SNL. At
    minimum, DOE considers the following positions as KMP: **1**)
    Chairman of the Board (COB), **2**) Chief Executive Officer
    (CEO)/President or Owner (Sole Proprietor), **3**) Facility Security
    Officer (FSO).

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-   All contractor personnel performing work at an SNL site must be DOE
    cleared and possess a DOE/SNL badge. [There are no exceptions for
    DOD certified company personnel]{.underline}.

> **Block 11 - [This Contract Will Require Access To.]{.underline}**
> Check appropriate box(s) specific to this PO/contract requirements.

Acronyms Definition are: SCI = Sensitive Compartmented Information;
ODCIC = Other Director of Central Intelligence Caveat; COMSEC:
Communication Security; FGI = Foreign Government Information; NATO =
North Atlantic Treaty Organization; Weapon Data (WD)/SIGMAS; or Other.

> **Block 12 - [In Performing this Contract, the Contractor
> Will.]{.underline}** Check appropriate box(s) specific to this
> PO/contract requirements. If a Contractor requires an "L-clearance"
> strictly for Sandia area access, check \"Perform Services that Require
> Unescorted Access to Security Areas.\" **NOTE**: Options in the second
> column apply only to activity at the contractor site.
>
> **Block 13 - [Classification Guidance.]{.underline}** When classified
> matter is being performed on or accessed, Block 13 must include:
>
> **1**) Identification of classification guidance,
>
> **2**) Identification of cognizant Sandia Derivative Classifier (DC)
> for the work being performed.
>
> A Statement of Work (SOW) must be attached to the CSCS form.
> Completion of this block must be coordinated with a Derivative
> Classifier (DC), if additional assistance is required, contact a
> \"Classification Analyst\" in Department 4225.
>
> **Block 14 - [Security Requirements.]{.underline}** The information
> entered in this block will contain any safeguards and security
> requirements imposed on the Contractor. ***Appropriate contract
> clauses must be incorporated into contract by the SCR. Note: The
> Security Requirements Clause (DEAR 952.204-2), applies to all
> contracts where personnel clearances will be required. The
> Classification/Declassification Clause (DEAR 952.204-70) is required
> [only]{.underline} when the contract will involve classified work.***
>
> ***[The Facility Clearance clause is utilized only on Solicitations.
> The Counterintelligence clause is for management contracts
> only]{.underline}.***
>
> **Block 15 - [Surveys.]{.underline}** The information entered in this
> block will identify the designated Surveying Office for the contract
> activity. ***(**The Security POC in SNL/NM or SNL/CA respectively will
> complete this block**)***
>
> **Blocks 16 a-e - [Certification and Signatures.]{.underline}**

**a** - Name of SNL Requester responsible for contract/agreement and
capable of responding to SNL Security and/or DOE questions concerning
contract/agreement,

**b** - Title , MS and Organization number of SNL Requester,

**c** - SNL Requester Phone and Fax number,

**d** - Mail Stop and Sandia National Laboratories address of SNL
Requester

**e** - By signing block 16e, requester certifies that security
requirements in blocks 10 through 13 are adequate for the performance of
contract, subcontract or agreement.

> **Blocks 17 - [Name of Contracting Official.]{.underline} Sandia
> Contracting Representative (SCR), responsible for placing and
> maintaining contract and the approving signature verifying CSCS
> information**
>
> **Block 18a - [Name of Classification Officer.]{.underline}**
> Signature of an SNL Classification Analyst will be obtained by the
> FSAC if an entry is required in block 13 (see direction for block
> 11a). The analyst certifies that guidance in block 13 is adequate for
> the performance of contract, subcontract or agreement.
>
> **Block 18b - [Signature of]{.underline} [Facility Approval &
> Registration of Activities Coordinator (FARAC)/Foreign Ownership,
> Control or Influence Coordinator (FOCIC) at SNL/NM or the Facility
> Survey and Approval Coordinator (FSAC) at SNL/CA.]{.underline}** By
> signing block 18b, the FARAC/FOCIC/FSAC certifies that CSCS form is
> complete and that all required reviews have been coordinated and
> completed.
>
> **Block 19a - [Name of Local DOE Security Officer.]{.underline}** Name
> of DOE Representative approving CSCS form. ***(**To be completed by
> DOE**)**.*
>
> **Block 19b - DOE Lead Responsible Office (LRO). *(****To be completed
> by DOE**)***
>
> **Block 20 - Required Distribution. *(****To be determined by
> DOE**)***
>
> **Block 21 - Comments. *(****DOE comments or Special information by
> the SNL Requester/SCR**)***
>
> **Note:**

-   The CSCS information is entered into the FSA Database in order to
    facilitate the badging of contractor personnel

+-----------+------------------------------------------------+--------+
| DOE F     | U. S. Department of Energy                     | **     |
| 470.1     |                                                | Page - |
|           | ###### Contrac                                 | 1 -**  |
| (12-05)   | t Security Classification Specification (CSCS) |        |
|           |                                                |        |
| Replaces  |                                                |        |
| DOE F     |                                                |        |
| 470.1     |                                                |        |
| (05-05)   |                                                |        |
|           |                                                |        |
| #         |                                                |        |
| #### All  |                                                |        |
| Other Edi |                                                |        |
| tions Are |                                                |        |
|  Obsolete |                                                |        |
+-----------+------------------------------------------------+--------+

<table>
<colgroup>
<col style="width: 8%" />
<col style="width: 4%" />
<col style="width: 5%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 6%" />
<col style="width: 9%" />
<col style="width: 2%" />
<col style="width: 0%" />
<col style="width: 39%" />
<col style="width: 14%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="4"><p>1. CSCS No.:</p>
<p>     </p></td>
<td colspan="4"><p>2. Previous CSCS No.:</p>
<p>     </p></td>
<td colspan="3"><p>3a. Reason for Acton:</p>
<p><em>(Check One)</em> Add Change Terminate</p>
<p>b. Item Numbers Modified:</p></td>
</tr>
<tr class="even">
<td colspan="8">4. This Specification is For: (Complete as
Applicable)</td>
<td colspan="3">5. Specification Is: (Complete as Applicable)</td>
</tr>
<tr class="odd">
<td colspan="8">(Check One)</td>
<td colspan="2"><blockquote>
<p>a. Original (Complete data in all cases)</p>
</blockquote></td>
<td>Date      </td>
</tr>
<tr class="even">
<td colspan="8"><p>a. Contract or Other Number Solicitation</p>
<p>Contract Type ________________</p></td>
<td colspan="2"><blockquote>
<p>b. Revised (Supercedes all previous specifications)</p>
</blockquote></td>
<td>Date      </td>
</tr>
<tr class="odd">
<td colspan="2">b. Contract Number:</td>
<td colspan="3">     </td>
<td>End Date:</td>
<td>     </td>
<td colspan="2"></td>
<td><blockquote>
<p>c. Certificate of Possession</p>
</blockquote></td>
<td>Date      </td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td colspan="3"></td>
<td></td>
<td>(Estimated)</td>
<td colspan="2"></td>
<td><blockquote>
<p>Retention of Classified Matter is Authorized Until</p>
</blockquote></td>
<td>Date      </td>
</tr>
<tr class="odd">
<td colspan="3">c. Contract Number of Prime:</td>
<td colspan="2">DE-AC04-94AL85000</td>
<td>End Date:</td>
<td>9/30/2008</td>
<td colspan="2"></td>
<td><blockquote>
<p>d. Final</p>
</blockquote></td>
<td>Date      </td>
</tr>
<tr class="even">
<td colspan="6">(Complete “C” if registering or soliciting a
subcontract)</td>
<td colspan="2">(Estimated)</td>
<td colspan="2"><blockquote>
<p>Certificate of Non Possession</p>
</blockquote></td>
<td>Date      </td>
</tr>
<tr class="odd">
<td colspan="11"><p>6. General identification of this Procurement</p>
<p>     </p></td>
</tr>
<tr class="even">
<td colspan="11">7. Contractor</td>
</tr>
<tr class="odd">
<td><p>a. Facility</p>
<p>Code</p>
<p>     </p></td>
<td colspan="7"><p>b. Name, Address, and Zip Code</p>
<p>     </p></td>
<td colspan="3"><p>c. Cognizant Security Office (Name, Address, and Zip
Code)</p>
<p>     </p></td>
</tr>
<tr class="even">
<td colspan="11">8. Prime Contractor (Complete if registering or
soliciting a subcontract)</td>
</tr>
<tr class="odd">
<td><p>a. Facility</p>
<p>Code</p>
<p>0501</p></td>
<td colspan="7"><p>b. Name, Address, and Zip Code</p>
<p>Sandia Corporation dba Sandia National Laboratories</p>
<p>1515 Eubank Blvd. (P.O. Box 5800)</p>
<p>Albuquerque, NM 87185</p>
<p>     </p></td>
<td colspan="3"><p>c. Cognizant Security Office (Name, Address, and Zip
Code)</p>
<p>NASC      </p></td>
</tr>
<tr class="even">
<td colspan="11">9. Actual Place of Performance <strong>(DOE
Facilities)</strong> (Attach additional entries as necessary on page
3)</td>
</tr>
<tr class="odd">
<td><p>a. Facility</p>
<p>Code</p>
<p>0501</p></td>
<td colspan="7"><p>b. Name, Address, and Zip Code</p>
<p>Sandia Corporation dba Sandia National Laboratories</p>
<p>1515 Eubank Blvd. (P.O. Box 5800)</p>
<p>Albuquerque, NM 87185</p></td>
<td colspan="3"><p>c. Cognizant Security Office (Name, Address, and Zip
Code)</p>
<p>NASC</p></td>
</tr>
<tr class="even">
<td colspan="11">Actual Place of Performance <strong>(NON DOE
Facilities)</strong> (Attach additional entries as necessary on page
3)</td>
</tr>
<tr class="odd">
<td><p>a. ID Code</p>
<p>     </p></td>
<td colspan="7"><p>b. Name, Address, and Zip Code</p>
<p>     </p></td>
<td colspan="3"><p>c. Cognizant Security Office (Name, Address, and Zip
Code)</p>
<p>     </p></td>
</tr>
<tr class="even">
<td colspan="8"><p>10. Clearance and Storage (enter level and
category)</p>
<p>A. Classification of Matter to be Accessed::</p>
<p> TSRD TSFRD TSNSI SRD SFRD SNSI</p>
<p> CRD CFRD CNSI U</p>
<p>B. Level of Storage Required at Contractor Facility:</p>
<p> TSRD TSFRD TSNSI SRD SFRD SNSI</p>
<p> CRD CFRD CNSI U</p>
<p>C. Level of Storage Required for this contract:</p>
<p> TSRD TSFRD TSNSI SRD SFRD SNSI</p>
<p> CRD CFRD CNSI U</p>
<p>D. Access Authorization Q L</p></td>
<td colspan="3"><p>11. This Contract Will Require Access To:</p>
<p> SCI</p>
<p> OTHER DCI CAVEAT</p>
<p> COMSEC</p>
<p> FGI</p>
<p> NATO</p>
<p> WD/SIGMA’S: <u>     </u></p>
<p> OTHER: <u>     </u></p></td>
</tr>
</tbody>
</table>

DOE F 470.1

(12-05)

Replaces DOE F 470.1 (05-05)

##### All Other Editions Are Obsolete U. S. Department of Energy

###### Contract Security Classification Specification (CSCS)

Page - 2 -

+-----------------------+-------+---+------------+-----------------------+
| 12\. In Performing    |       |   |            |                       |
| this Contract, the    |       |   |            |                       |
| Contractor Will:      |       |   |            |                       |
+-----------------------+-------+---+------------+-----------------------+
| Have Access to        |       |   |            |                       |
| Classified            |       | R |            |                       |
| Information Only at   |       | e |            |                       |
| Another Contractor's  |       | c |            |                       |
|                       |       | e |            |                       |
| Facility or a         |       | i |            |                       |
| Government Activity   |       | v |            |                       |
|                       |       | e |            |                       |
| Generate Classified   |       | C |            |                       |
| Matter                |       | l |            |                       |
|                       |       | a |            |                       |
| Perform Services That |       | s |            |                       |
| Require Unescorted    |       | s |            |                       |
| Access to Security    |       | i |            |                       |
| Areas                 |       | f |            |                       |
|                       |       | i |            |                       |
| Have Access to U.S.   |       | e |            |                       |
| Classified            |       | d |            |                       |
| Information Outside   |       | M |            |                       |
| the U.S.,             |       | a |            |                       |
|                       |       | t |            |                       |
| Puerto Rico, U.S.     |       | t |            |                       |
| Possessions and Trust |       | e |            |                       |
| Territories           |       | r |            |                       |
|                       |       |   |            |                       |
| Other (Specify)       |       | F |            |                       |
|                       |       | a |            |                       |
|                       |       | b |            |                       |
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|                       |       | s |            |                       |
|                       |       | s |            |                       |
|                       |       | i |            |                       |
|                       |       | f |            |                       |
|                       |       | i |            |                       |
|                       |       | e |            |                       |
|                       |       | d |            |                       |
|                       |       | M |            |                       |
|                       |       | a |            |                       |
|                       |       | t |            |                       |
|                       |       | t |            |                       |
|                       |       | e |            |                       |
|                       |       | r |            |                       |
|                       |       |   |            |                       |
|                       |       | R |            |                       |
|                       |       | e |            |                       |
|                       |       | q |            |                       |
|                       |       | u |            |                       |
|                       |       | i |            |                       |
|                       |       | r |            |                       |
|                       |       | e |            |                       |
|                       |       | a |            |                       |
|                       |       | C |            |                       |
|                       |       | O |            |                       |
|                       |       | M |            |                       |
|                       |       | S |            |                       |
|                       |       | E |            |                       |
|                       |       | C |            |                       |
|                       |       | A |            |                       |
|                       |       | c |            |                       |
|                       |       | c |            |                       |
|                       |       | o |            |                       |
|                       |       | u |            |                       |
|                       |       | n |            |                       |
|                       |       | t |            |                       |
|                       |       |   |            |                       |
|                       |       | B |            |                       |
|                       |       | e |            |                       |
|                       |       | A |            |                       |
|                       |       | u |            |                       |
|                       |       | t |            |                       |
|                       |       | h |            |                       |
|                       |       | o |            |                       |
|                       |       | r |            |                       |
|                       |       | i |            |                       |
|                       |       | z |            |                       |
|                       |       | e |            |                       |
|                       |       | d |            |                       |
|                       |       | t |            |                       |
|                       |       | o |            |                       |
|                       |       | U |            |                       |
|                       |       | s |            |                       |
|                       |       | e |            |                       |
|                       |       | t |            |                       |
|                       |       | h |            |                       |
|                       |       | e |            |                       |
|                       |       | D |            |                       |
|                       |       | e |            |                       |
|                       |       | f |            |                       |
|                       |       | e |            |                       |
|                       |       | n |            |                       |
|                       |       | s |            |                       |
|                       |       | e |            |                       |
|                       |       | C |            |                       |
|                       |       | o |            |                       |
|                       |       | u |            |                       |
|                       |       | r |            |                       |
|                       |       | i |            |                       |
|                       |       | e |            |                       |
|                       |       | r |            |                       |
|                       |       | S |            |                       |
|                       |       | e |            |                       |
|                       |       | r |            |                       |
|                       |       | v |            |                       |
|                       |       | i |            |                       |
|                       |       | c |            |                       |
|                       |       | e |            |                       |
+-----------------------+-------+---+------------+-----------------------+
| 13\. Classification   |       |   |            |                       |
| Guidance              |       |   |            |                       |
|                       |       |   |            |                       |
| > The classification  |       |   |            |                       |
| > guidance needed for |       |   |            |                       |
| > this classified     |       |   |            |                       |
| > effort is           |       |   |            |                       |
| > identified below.   |       |   |            |                       |
| > Note: Guidance      |       |   |            |                       |
| > which is in itself  |       |   |            |                       |
| > classified should   |       |   |            |                       |
| > be referenced here  |       |   |            |                       |
| > and provided under  |       |   |            |                       |
| > separate cover      |       |   |            |                       |
| >                     |       |   |            |                       |
| >                     |       |   |            |                       |
| >                     |       |   |            |                       |
| > Cognizant           |       |   |            |                       |
| > Authorized          |       |   |            |                       |
| > Derivative          |       |   |            |                       |
| > Classifier: Name    |       |   |            |                       |
| >       Title         |       |   |            |                       |
| > Dept.       Phone   |       |   |            |                       |
| >       Mail Stop     |       |   |            |                       |
| >                     |       |   |            |                       |
+-----------------------+-------+---+------------+-----------------------+
| 14\. Security         |       |   |            |                       |
| Requirements          |       |   |            |                       |
|                       |       |   |            |                       |
| > Security            |       |   |            |                       |
| > requirements are    |       |   |            |                       |
| > established for     |       |   |            |                       |
| > this contract are   |       |   |            |                       |
| > identified in the   |       |   |            |                       |
| > following           |       |   |            |                       |
| > c                   |       |   |            |                       |
| ontracts/solicitation |       |   |            |                       |
| > clauses.            |       |   |            |                       |
| >                     |       |   |            |                       |
| > Dear 952.204-2      |       |   |            |                       |
| > Security            |       |   |            |                       |
| > Requirements Dear   |       |   |            |                       |
| > 952.204-73 Facility |       |   |            |                       |
| > Clearance           |       |   |            |                       |
| > (Acquisition Letter |       |   |            |                       |
| > 99-03)              |       |   |            |                       |
| > (Solicitations)     |       |   |            |                       |
| >                     |       |   |            |                       |
| > Dear 952.204-70     |       |   |            |                       |
| > Classifica          |       |   |            |                       |
| tion/Declassification |       |   |            |                       |
| > DEAR 970.5204.1     |       |   |            |                       |
| > Counterintelligence |       |   |            |                       |
| > (For Management     |       |   |            |                       |
| > Contracts ONLY)     |       |   |            |                       |
| >                     |       |   |            |                       |
| > Note: The Security  |       |   |            |                       |
| > Requirements Clause |       |   |            |                       |
| > has been modified   |       |   |            |                       |
| > to include FOCI     |       |   |            |                       |
| > Language.           |       |   |            |                       |
+-----------------------+-------+---+------------+-----------------------+
| 15\. Surveys          |       |   |            |                       |
|                       |       |   |            |                       |
| > DOE Surveying       |       |   |            |                       |
| > Office is           |       |   |            |                       |
| > [     ]{.underline} |       |   |            |                       |
| >                     |       |   |            |                       |
| > Elements of this    |       |   |            |                       |
| > contract are        |       |   |            |                       |
| > outside the survey  |       |   |            |                       |
| > responsibility of   |       |   |            |                       |
| > the lead            |       |   |            |                       |
| > responsible office  |       |   |            |                       |
| > and/or the          |       |   |            |                       |
| > surveying office.   |       |   |            |                       |
| >                     |       |   |            |                       |
| > No Yes (Identify    |       |   |            |                       |
| > specific areas and  |       |   |            |                       |
| > provide             |       |   |            |                       |
| > expl                |       |   |            |                       |
| anation/justification |       |   |            |                       |
| > for each)           |       |   |            |                       |
| >                     |       |   |            |                       |
| >                     |       |   |            |                       |
+-----------------------+-------+---+------------+-----------------------+
| 16\. Certification    |       |   |            |                       |
| and Signature.        |       |   |            |                       |
| Security requirements |       |   |            |                       |
| stated herein are     |       |   |            |                       |
| complete and adequate |       |   |            |                       |
| for safeguarding the  |       |   |            |                       |
| classified            |       |   |            |                       |
| information to be     |       |   |            |                       |
| released or generated |       |   |            |                       |
| under this classified |       |   |            |                       |
| contract. All         |       |   |            |                       |
| questions shall be    |       |   |            |                       |
| referred to the       |       |   |            |                       |
| official named below. |       |   |            |                       |
+-----------------------+-------+---+------------+-----------------------+
| A. Typed Name of      | B.    |   |            | C. Telephone & Fax    |
| Procurement Request   | T     |   |            | (include Area Code)   |
| Originator            | itle, |   |            |                       |
|                       | Mail  |   |            |                       |
|                       | Stop  |   |            |                       |
|                       | and   |   |            |                       |
|                       | Or    |   |            |                       |
|                       | ganiz |   |            |                       |
|                       | ation |   |            |                       |
|                       | N     |   |            |                       |
|                       | umber |   |            |                       |
|                       |       |   |            |                       |
|                       |       |   |            |                       |
+-----------------------+-------+---+------------+-----------------------+
| D. Address (include   |       |   | E.         |                       |
| Zip Code)             |       |   |            |                       |
|                       |       |   | >          |                       |
|                       |       |   |  Signature |                       |
|                       |       |   | > \_       |                       |
|                       |       |   | \_\_\_\_\_ |                       |
|                       |       |   | \_\_\_\_\_ |                       |
|                       |       |   | \_\_\_\_\_ |                       |
|                       |       |   | \_\_\_\_\_ |                       |
|                       |       |   | \_\_\_\_\_ |                       |
|                       |       |   | \_\_\_\_\_ |                       |
|                       |       |   | \_\_\_\_\_ |                       |
|                       |       |   | \_\_\_\_\_ |                       |
|                       |       |   | \_\_\_\_\_ |                       |
|                       |       |   | >          |                       |
|                       |       |   | > Date     |                       |
|                       |       |   | > \_       |                       |
|                       |       |   | \_\_\_\_\_ |                       |
|                       |       |   | \_\_\_\_\_ |                       |
|                       |       |   | \_\_\_\_\_ |                       |
|                       |       |   | \_\_\_\_\_ |                       |
+-----------------------+-------+---+------------+-----------------------+
| 17\. Typed Name of    |       |   | >          |                       |
| Contracting Official  |       |   |  Signature |                       |
|                       |       |   | > \_       |                       |
| Org.       Mail Stop  |       |   | \_\_\_\_\_ |                       |
|       Phone           |       |   | \_\_\_\_\_ |                       |
|                       |       |   | \_\_\_\_\_ |                       |
|                       |       |   | \_\_\_\_\_ |                       |
|                       |       |   | \_\_\_\_\_ |                       |
|                       |       |   | \_\_\_\_\_ |                       |
|                       |       |   | \_\_\_\_\_ |                       |
|                       |       |   | \_\_\_\_\_ |                       |
|                       |       |   | \_\_\_\_\_ |                       |
|                       |       |   | >          |                       |
|                       |       |   | > Date     |                       |
|                       |       |   | > \_       |                       |
|                       |       |   | \_\_\_\_\_ |                       |
|                       |       |   | \_\_\_\_\_ |                       |
|                       |       |   | \_\_\_\_\_ |                       |
|                       |       |   | \_\_\_\_\_ |                       |
+-----------------------+-------+---+------------+-----------------------+
| 18a. Typed Name of    |       |   | 18b. Typed |                       |
| Classification        |       |   | Name of    |                       |
| Officer (Approval of  |       |   | FARA/FOCI  |                       |
| Block 13)             |       |   | C          |                       |
|                       |       |   | oordinator |                       |
| Name                  |       |   |            |                       |
| [     ]{.underline}   |       |   | Name       |                       |
|                       |       |   | [     ]{.  |                       |
| Content on this form  |       |   | underline} |                       |
| is unclassified.      |       |   |            |                       |
|                       |       |   | Signature  |                       |
| Signature             |       |   | \_\_\_\_   |                       |
| \_\_                  |       |   | \_\_\_\_\_ |                       |
| \_\_\_\_\_\_\_\_\_\_\ |       |   | \_\_\_\_\_ |                       |
| _\_\_\_\_\_\_\_\_\_\_ |       |   | \_\_\_\_\_ |                       |
| \_\_\_\_\_\_\_\_\_\_\ |       |   | \_\_\_\_\_ |                       |
| _\_\_\_\_\_\_\_\_\_\_ |       |   | \_\_\_\_\_ |                       |
|                       |       |   | \_\_\_\_\_ |                       |
| Date                  |       |   | \_\_\_\_\_ |                       |
| [     ]{.underline}   |       |   | \_\_\_\_\_ |                       |
|                       |       |   |            |                       |
|                       |       |   | > Date     |                       |
|                       |       |   | >          |                       |
|                       |       |   |  [     ]{. |                       |
|                       |       |   | underline} |                       |
+-----------------------+-------+---+------------+-----------------------+

+---------------------------------+------------------------------------+
| 19a. Typed Name of Local DOE    | > Signature                        |
| Security Officer                | > \_\_\_\_\_\_\_\_\_\_\_\_         |
|                                 | \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
| a\. Responsible Office          | \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
|                                 | >                                  |
|                                 | > Date                             |
|                                 | > \_\_\_\_                         |
|                                 | \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
+---------------------------------+------------------------------------+
| 20\. Required Distribution      |                                    |
|                                 |                                    |
| > Contractor Administering      |                                    |
| > Contracting Officer           |                                    |
| >                               |                                    |
| > Subcontractor Surveying       |                                    |
| > Office If Different than LRO  |                                    |
| >                               |                                    |
| > Lead Responsible Office (LRO) |                                    |
| > Others, as Necessary          |                                    |
+---------------------------------+------------------------------------+
| 21\. General Comments:          |                                    |
|                                 |                                    |
|                                 |                                    |
+---------------------------------+------------------------------------+

+---+-----+----+-------------------+---------------------------+---------+---+
| # |     |    | U. S. Department  |                           | ###     |   |
| # |     |    | of Energy         |                           | ######  |   |
| # |     |    |                   |                           |         |   |
| # |     |    | ###### Co         |                           | ###     |   |
| # |     |    | ntract Security C |                           | ######  |   |
|   |     |    | lassification Spe |                           |         |   |
|   |     |    | cification (CSCS) |                           | ###     |   |
|   |     |    |                   |                           | ######  |   |
|   |     |    | ##                |                           |         |   |
|   |     |    | ##### Actual Plac |                           |         |   |
|   |     |    | e of Performance  |                           |         |   |
|   |     |    | (Continued Space) |                           |         |   |
+---+-----+----+-------------------+---------------------------+---------+---+
|   |     |    |                   |                           |         |   |
+---+-----+----+-------------------+---------------------------+---------+---+
|   | 9\. |    |                   |                           |         |   |
|   | Act |    |                   |                           |         |   |
|   | ual |    |                   |                           |         |   |
|   | Pl  |    |                   |                           |         |   |
|   | ace |    |                   |                           |         |   |
|   | of  |    |                   |                           |         |   |
|   | Pe  |    |                   |                           |         |   |
|   | rfo |    |                   |                           |         |   |
|   | rma |    |                   |                           |         |   |
|   | nce |    |                   |                           |         |   |
|   | --  |    |                   |                           |         |   |
|   | **  |    |                   |                           |         |   |
|   | DOE |    |                   |                           |         |   |
|   | Fac |    |                   |                           |         |   |
|   | ili |    |                   |                           |         |   |
|   | tie |    |                   |                           |         |   |
|   | s** |    |                   |                           |         |   |
+---+-----+----+-------------------+---------------------------+---------+---+
|   | a\. | b  |                   | c\. Cognizant Security    |         |   |
|   | Fa  | \. |                   | Office (Name, Address,    |         |   |
|   | cil | N  |                   | and Zip Code)             |         |   |
|   | ity | am |                   |                           |         |   |
|   |     | e, |                   |                           |         |   |
|   | C   | Ad |                   |                           |         |   |
|   | ode | dr |                   |                           |         |   |
|   |     | es |                   |                           |         |   |
|   |     | s, |                   |                           |         |   |
|   |     | a  |                   |                           |         |   |
|   |     | nd |                   |                           |         |   |
|   |     | Z  |                   |                           |         |   |
|   |     | ip |                   |                           |         |   |
|   |     | Co |                   |                           |         |   |
|   |     | de |                   |                           |         |   |
|   |     |    |                   |                           |         |   |
|   |     |    |                   |                           |         |   |
|   |     |    |                   |                           |         |   |
|   |     |    |                   |                           |         |   |
+---+-----+----+-------------------+---------------------------+---------+---+
|   | a\. | b  |                   | c\. Cognizant Security    |         |   |
|   | Fa  | \. |                   | Office (Name, Address,    |         |   |
|   | cil | N  |                   | and Zip Code)             |         |   |
|   | ity | am |                   |                           |         |   |
|   |     | e, |                   |                           |         |   |
|   | C   | Ad |                   |                           |         |   |
|   | ode | dr |                   |                           |         |   |
|   |     | es |                   |                           |         |   |
|   |     | s, |                   |                           |         |   |
|   |     | a  |                   |                           |         |   |
|   |     | nd |                   |                           |         |   |
|   |     | Z  |                   |                           |         |   |
|   |     | ip |                   |                           |         |   |
|   |     | Co |                   |                           |         |   |
|   |     | de |                   |                           |         |   |
|   |     |    |                   |                           |         |   |
|   |     |    |                   |                           |         |   |
|   |     |    |                   |                           |         |   |
|   |     |    |                   |                           |         |   |
+---+-----+----+-------------------+---------------------------+---------+---+
|   | a\. | b  |                   | c\. Cognizant Security    |         |   |
|   | Fa  | \. |                   | Office (Name, Address,    |         |   |
|   | cil | N  |                   | and Zip Code)             |         |   |
|   | ity | am |                   |                           |         |   |
|   |     | e, |                   |                           |         |   |
|   | C   | Ad |                   |                           |         |   |
|   | ode | dr |                   |                           |         |   |
|   |     | es |                   |                           |         |   |
|   |     | s, |                   |                           |         |   |
|   |     | a  |                   |                           |         |   |
|   |     | nd |                   |                           |         |   |
|   |     | Z  |                   |                           |         |   |
|   |     | ip |                   |                           |         |   |
|   |     | Co |                   |                           |         |   |
|   |     | de |                   |                           |         |   |
|   |     |    |                   |                           |         |   |
|   |     |    |                   |                           |         |   |
|   |     |    |                   |                           |         |   |
|   |     |    |                   |                           |         |   |
+---+-----+----+-------------------+---------------------------+---------+---+

+-----+-------------------------+--------------------------------------+
| **9 |                         |                                      |
| .** |                         |                                      |
| Act |                         |                                      |
| ual |                         |                                      |
| Pl  |                         |                                      |
| ace |                         |                                      |
| of  |                         |                                      |
| Pe  |                         |                                      |
| rfo |                         |                                      |
| rma |                         |                                      |
| nce |                         |                                      |
| --  |                         |                                      |
| **  |                         |                                      |
| NON |                         |                                      |
| DOE |                         |                                      |
| Fac |                         |                                      |
| ili |                         |                                      |
| tie |                         |                                      |
| s** |                         |                                      |
+-----+-------------------------+--------------------------------------+
| a\. | b\. Name, Address, and  | c\. Cognizant Security Office (Name, |
| ID  | Zip Code                | Address, and Zip Code)               |
| C   |                         |                                      |
| ode |                         |                                      |
|     |                         |                                      |
|     |                         |                                      |
|     |                         |                                      |
+-----+-------------------------+--------------------------------------+
| a\. | b\. Name, Address, and  | c\. Cognizant Security Office (Name, |
| ID  | Zip Code                | Address, and Zip Code)               |
| C   |                         |                                      |
| ode |                         |                                      |
|     |                         |                                      |
|     |                         |                                      |
|     |                         |                                      |
+-----+-------------------------+--------------------------------------+
| a\. | b\. Name, Address, and  | c\. Cognizant Security Office (Name, |
| ID  | Zip Code                | Address, and Zip Code)               |
| C   |                         |                                      |
| ode |                         |                                      |
|     |                         |                                      |
|     |                         |                                      |
|     |                         |                                      |
+-----+-------------------------+--------------------------------------+