Jacket: 747‐942

Title: Pub 10050‐LE Medicare and You 2024 LP

Agency: DHHS/CMS

Bid Opening: August 23, 2023 at 1:00 PM

Bid Terms Discounted Total

$106,318.00 5.0% 21 days $101,002.10

$123,145.59 0.25% 20 days $122,837.73

PA Hutchison

Contractor Name

Advantage Mailing

Awarded
Specifications by TB Jacket 747-942

Reviewed by EBR DHHS/CMS (4120-01) Req. 3-00131

Page 1 of 9

BID OPENING: Bids shall be opened at 1:00 p.m., prevailing Central Standard Time (CST), on August 23, 2023

for the U.S. Government Publishing Office, Southcentral Region.

ISSUE DATE: August 17, 2023

ANY QUESTIONS BEFORE AWARD CONCERNING THESE SPECIFICATIONS, CALL (214) 767-0451, EXT. 8 

(TOM BACON).

SPECIFICATIONS

U.S. Government Publishing Office (GPO)

Southcentral Region

GPO CONTRACT TERMS: Any contract which results from this Invitation for Bid will be subject to the applicable

provisions, clauses, and supplemental specifications of GPO Contract Terms (GPO Publication 310.2, effective 

December 1, 1987 (Rev. 01-18)) and GPO Contract Terms, Quality Assurance Through Attributes Program for

Printing and Binding (GPO Publication 310.1, effective May 1979 (Rev. 09-19)).

PRODUCT: Thisspecification isfor proofing, printing, binding, packing, mailing and shipping of comb bound books, 

with secure handling of PII required.

TITLE: Pub. 10050-LE Medicare and You 2024 - LP

QUALITY LEVEL: III Quality Assurance Through Attributes (GPO Pub 310.1, effective May 1979 (Rev. 09-19)

applies.

QUANTITY: 15,646 Books

PAGES: 320 plus covers (includes divider page). See Description.

TRIM SIZE: 8-1/2 X 11”

DESCRIPTION: Black plastic comb bound book prints head to head in 4 Color Process. Covers 1 thru 4, text and 

divider page print type and line matter, medium ink coverage of black, and light ink coverage in yellow as highlight to 

text. Close registration throughout. One divider leaf for Pages 263 and 264 (bound) prints on white index stock.

SECURITY REQUIRMENTS: Contractor must maintain 100% accountability in the accuracy of imaging and 

mailing of all pieces throughout run. The Contractor must ensure that there are no missing or duplicate pieces and/or 

pieces with mis-imaged data. The Contractor must also ensure that no defective pieces enter the mail stream.

It is the contractor's responsibility to properly safeguard personally identifiable information (PII) from loss, theft, or 

inadvertent disclosure and to immediately notify the Government of any loss of personally identifiable information. PII 

is "information which can be used to distinguish or trace an individual's identity, such as their name, social security 

number, biometric records, etc., alone, or when combined with other personal or identifying information which is 

linked or linkable to a specific individual, such as date and place of birth, mother's maiden name, etc." (Ref.: OMB 

Memorandum 07-16.) Other specific examples of PII include, but are not limited to:

a. Personal identification number, such as passport number, driver's license number, taxpayer identification

number, or financial account or credit card number;

b. Address information, such as street address or personal email address;

c. Personal characteristics, including photographic image (especially of face or other distinguishing
Jackets 747-942 Page 2 of 9

characteristic), fingerprints, handwriting, or other biometric image or template data (e.g., retina scans, voice

signature, facial geometry).

SECURITY CONTROL PLAN: The contractor shall maintain in operation, an effective security system where items 

by these specifications are manufactured and/or stored (awaiting distribution or disposal) to assure against theft and/or 

the product ordered falling into unauthorized hands.

Contractor is cautioned that no Government provided information shall be used for non- government business. 

Specifically, no Government information shall be used for the benefit of a third party.

The Government retains the right to conduct on-site security reviews at any time during the term of the contract.

The plan shall contain at a minimum:

(1) How Government files (data) will be secured to prevent disclosure to a third party prior to and after termination of 

contract;

(2) Explain how all accountable materials will be handled throughout all phases of production

(3) How the disposal of waste materials will be handled;

(4) How all applicable Government-mandated security/privacy/rules and regulations as cited in this contract shall be 

adhered to by the contractor.

This proposed plan is subject to review and approval by the Government and award will not be made prior to approval 

of same.

Addresses for Mail copies will be furnished in the following method: Electronic file transmission (EFT), the contractor 

must obtain approval from CMS IT Security for access to CMS computer systems.

Files are furnished by EFT, a Gentran Mailbox will be setup by CMS to provide access to data files. Immediately after 

award, the contractor must submit two (one primary user, and on back-up user) completed APPLICATION FOR 

ACCESS TO CMS COMPUTER SYSTEMS at the following internet link:

http://www.cms.hhs.gov/InformationSecurity/Dowloads/EUAaccessform.pdf . The contractor must complete Section 

2, User Information on page 1, and the Applicants Information on page 3 on the Form.

Please note that the Applicants Social Security Number must be provided in order to receive a USERID and

gain access to CMS computer systems. Corporate Tax Identification Numbers are not accepted in lieu of individual 

SSN's. The contractor must reapply for access every 12 months during the term of the contract.

Security Exhibits: The following exhibits A through H (See Attachment #2) contain security clauses,

information, and forms:

Exhibit A: CMS Clause 11: CMS Information Security

Exhibit B: CMS Clause 09A-01 Security Clause

Exhibit C: FAQ Supplement to CMS Security Clause 09A-01

Exhibit D: HHS identification (ID) Badge Request HHS-Form 745 (5/07)

(This form is used to initiate background investigations of the two people applying for access to the Gentran mailbox. 

No physical access, or badge, to CMS will be granted. Applicants must complete page 1 in its entirety including the 

applicant signature along with the date. After completing the form, return all pages to CMS within 24 hours. This form 

is to be submitted prior to award and renew annually thereafter if applicable.)

Exhibit E: Application for Access to CMS Computer Systems (Form CMS-20037) (The same applicants submitting the 

Form-745 must complete Form CMS-20037, and submit to CMS within 24 hours via an overnight courier, prior to 

award and renew annually thereafter if applicable.)
Jackets 747-942 Page 3 of 9

Exhibit F: Data Use Agreement (DUA) (Form CMS-R-0235) (Contractor management must complete CMS-R-0235, 

and submit it to CMS prior to award within 24 hours.

Exhibit G: Certificate of Data Destruction (Form CMS-10252) (Contractor must complete CMS-10252 at the 

expiration of the DUA.)

Exhibit H: Secure One HHS, Information Security Program Rules of Behavior

NOTE: These forms are provided as attachments (PDF file). See below. A MS Word file will be sent with

the GFM upon award.

All contractor management and employees involved in this contract must read and sign this document. Signed copies 

of this document for Gentran applicants and DUA applicants must be submitted to CMS immediately prior to award. 

Signed copies for all other employees will be maintained by the contractor and furnished to the Government upon 

request.

The contractor must submit all completed and signed security forms (original signatures only, no photocopy or 

facsimile signatures will be accepted) via an overnight courier to: CMS, Attn: Clint Howard SLL-11-17 (410-786-

1962); 7500 Security Blvd, Baltimore, MD 21244. For delivery directly to Attn: Clint Howard SLL-11-17 (410-786-

1962); the contractor is encouraged to use an overnight/express mail contractor as determined by CMS.

GOVERNMENT TO FURNISH: Adobe Acrobat file (fonts included and color mode CMYK) for print files and a 

MS Excel spreadsheet for the bulk shipments (See Attachment #1) will be e-mailed at time of award. A Gentran 

Mailbox will be setup by CMS to provide access to data files for the addresses for the self-mailer copies.

ADDITIONAL INFORMATION:

- Contractor must have the ability to edit PDF files (when furnished by the Government).

- Contractor is not to request that electronic files provided be converted to a different format. If contractor wishes to 

convert files to a different format, the final output must be of the same or higher quality and at no additional cost to the 

Government.

- The contractor is cautioned that furnished fonts are the property of the Government and/or its originator. All furnished 

fonts are to be eliminated from the contractor's archive immediately after completion of the contract.

- Identification markings such as register marks, commercial identification marks of any kind, etc., GPO imprint, form 

number and revision date, carried in the electronic files, must not print on the finished product.

- Prior to image processing, the contractor shall perform a basic check (preflight) of the furnished media and publishing 

files to assure correct output of the required reproduction image. Any errors, media damage or data corruption that might 

interfere with proper file image processing must be reported to your contract administrator.

- The contractor shall create/alter any necessary trapping, set proper screen angles and screen frequency, and define file 

output selection for the imaging device being utilized. Furnished files must be imaged as necessary to meet the assigned 

quality level.

- When PostScript Files are not furnished - prior to making revisions, the contractor shall copy the furnished files and 

make all changes to the copy. 

STOCK/PAPER: The specifications of all paper furnished must be in accordance with those listed herein or listed for 

the corresponding JCP Code numbers in the Government Paper Specification Standards, No. 13, dated September 2019.

Covers & Divider: JCP Code* K10, Index, White, Basis Size 25.5 X 30.5" Basis Weight 110 lb.

Text: JCP Code* A60, Uncoated Text, White, Basis Size 25 X 38" Basis Weight 60 lb.

INK: Four Color Process

MARGINS: Adequate gripper.

PROOFS: Contractor to submit one Press Quality PDF soft proof (for content only) using the same Raster Image 

Processor (RIP) that will be used to produce the final printed product. PDF proofs will be evaluated for text flow, 

image position, and color breaks. Proof will not be used for color match. Contractor must call 214-767-0451 x 8 to 

confirm receipt.

Email proofs on or before August 30, 2023.
Jackets 747-942 Page 4 of 9 

The proofs will be checked for quality and compliance with these specifications, approved or approved with comments 

and the contractor will be notified within TWO (2) working day after receipt. If, in the opinion of the GPO and/or 

Department, the proofs are not a true representation of the furnished copy, or contain noticeable defects they will be 

rejected must be corrected and reproofed at no additional expense to the Government. The schedule stated elsewhere in 

these specifications CANNOT be extended to allow for such reproofing.

Email proofs to Clinton.Howard@cms.hhs.gov; contractor must also copy contract administrator at tbacon@gpo.gov. 

GPO jacket numbers 747-942 must appear on all correspondence.

NOTE: The day the email is sent is not the first workday of the schedule.

CONTRACTOR MUST NOT PRINT PRIOR TO RECEIVING AN "OK TO PRINT"

CONTRACTOR TO FURNISH: All materials and operations, other than those listed under "Government to

Furnish," necessary to produce the product(s) in accordance with these specifications.

BINDING: Suitably punch along the left 11" dimension and insert black plastic combs of suitable size and capacity to 

ensure book lies flat when opened.

PACKING/LABELING: Mark shipping containers as follows:

Pub # 10050-LE 09-23 and ICN # 005269 on all carton labels

****Contractor must label all shipping packages with "Free Matter For The Blind".  

Contractor must package mailed quantity, in individual mailing containers, to insure damage is not incurred during 

mailing and to meet all USPS postal requirements for standard mail.

Shrink film wrap suitable.

Pack NTE 40 lbs. per shipping container.

Pallets (required for motor freight shipments only): Pallets must be type III and must conform with Federal

Specifications NN-P-71C, and any amendments thereto except for dimensions and single center stringer. Full entry 

MUST be on the 40" width. Receipt of incorrect pallets may result in a charge for each incorrect pallet which will be 

assessed against the contractor. This charge will cover additional costs incurred by CMS to repalletize the shipment 

onto correct pallets. Loaded pallets must be machine wrapped with shrinkable or stretchable plastic strong enough to 

retain the integrity of the pallet during transportation and handling. Do NOT use metal strapping or pallet caps for 

securing material on pallets. There must be no more than one partial pallet per destination.

SCHEDULE:

Award will be made and Purchase Order issued by August 25, 2023. 

PDF Proofs will be due to deliver to agency and GPO on or before August 30, 2023. 

INDIVIDUAL SHIPMENTS: 8,594 single copies mail f.o.b. contractor's city on or before September 29, 

2023. 

BULK SHIPMENTS: Contractor to deliver 7,050 books to 158 locations in various quantities from single

copy to 2,500 copies from distribution list, plus 2 department copies deliver f.o.b. destination on or before

October 13, 2023. 
Jackets 747-942 Page 5 of 9 

DISTRIBUTION: F.O.B. destination and F.O.B. contractor's city/origin - See Below 

All expenses incidental to picking up and returning materials, and furnishing samples must be borne by the contractor. 

Also, refer to Articles 5 and 6, Supplemental Specifications, GPO Contract Terms, Publication 310.2, revised January 

2018.

Mail FOB Contractor's City 8,594 individual copies in self-mailers using a contractor created "Free Matter for the 

Blind" indicia. Contractor to create mailing indicia. Ensure positioning of address/permit info is in accordance with 

current applicable postal regulations. Evidence of mailing must accompany the contractor's invoice for billing.

See MAIL PREPARATION and ADDRESS REQUIREMENTS below.

All shipments below are FOB Destination. INCLUDE CHARGES FOR THESE DELIVERIES IN THE QUOTED 

PRICE. 

7,050 copies to 158 destinations. See attached distribution list (Attachment #1). 

Centers for Medicare & Medicaid Services

Attn: Clint Howard SLL-11-17 (410-786-1962)

7500 Security Blvd

Baltimore, MD 21244

----- 2 books

ADDRESS REQUIREMENTS: Address placement, format, and fonts must be consistent with current U.S. Postal 

Service (USPS) Address Quality Standards, and in accordance with appropriate USPS rules and regulations including 

USPS Domestic Mail Manual (DMM) in effect at the time of mailing. The type font must be one of the USPS accepted 

fonts. 

MAIL PREPARATION: It is the contractor’s responsibility to keep up to date on all USPS requirements and current 

DMM.

Using the CMS address information as provided, the contractor is required to obtain the maximum USPS postage 

discounts possible. In compliance with USPS Mail Preparation & Sortation Regulations, all mail must be appropriately 

marked and supported with the documentation necessary to ensure USPS acceptance.

Mailing Envelopes must be prepared and sealed in a manner that will ensure acceptance, security and safe delivery by 

the U.S. Postal Service. Gather each piece and insert into mailing envelope, and seal. The contractor must provide all 

mailing materials, as well as all labeling and marking, as necessary to fulfill mailing and distribution requirements. 

Noncompliance with the packing and labeling instructions will be cause for the Government to take corrective action 

in accordance with GPO Pub. 310.2.

Contractor must be able to read/print up to ten lines of address information and insure all addresses can display address 

format acceptable for USPS automation processing. Addresses for this mailing come from a Government maintained 

file. For this mailing, CMS will provide certificates indicating that within 95 days the addresses have been matched 

against both the USPS required Coding Accuracy Support System (CASS) and National Change of Address (NCOA) 

software.

In the event the CASS and NCOA certification has expired, the contractor may be required to provide the certification 

prior to mailing. Reimbursement for this service will be made via contract modification.

Contractor sponsored address data enhancements to secure postal discount MUST NOT negatively affect deliverability 

and/or omit/change any required address field as provided by CMS address files.

COMPLIANCE REPORTING: Contractor must notify the ordering agency on the same day that the product 

ships/delivers via e-mail to Clinton Howard (clinton.howard@cms.hhs.gov ) and Tom Bacon (tbacon@gpo.gov ). The 

subject line of this message shall be "Distribution Notice for Jacket 747-942, Req 3-00131. The notice must provide all 
Jackets 747-942 Page 6 of 9 

applicable tracking numbers, shipping method, and title. Contractor must be able to provide copies of all delivery, 

mailing, and shipping receipts upon agency request.

NOTIFICATION OF SHIPMENT: Immediately after the order has been shipped, the contractor MUST furnish 

shipping information to Agency. Include the order title, GPO jacket number, requisition number, date of shipment, 

quantity (copies, # of cartons, etc.), and tracking information for deliveries. Email clinton.howard@cms.hhs.gov,

infosouthcentral@gpo.gov and tbacon@gpo.gov.

QUALITY ASSURANCE THROUGH ATTRIBUTES: The bidder agrees that any contract resulting from bidder’s offer 

under these specifications shall be subject to the terms and conditions of GPO Pub. 310.1 “Quality AssuranceThrough

Attributes – Contract Terms” in effect on the date of issuance of the invitation for bid. GPO Pub 310.1 is available at

https://www.gpo.gov/docs/default-source/forms-and-standards-files-for-vendors/qatap-rev-09-19.pdf

LEVELS AND STANDARDS: The following levels and standards shall apply to these specifications:

Product Quality Levels:

(a) Printing (page related) Attributes – Level III 

(b) Finishing (item related) Attributes – Level III 

(c) Inspection Levels (from ANSI/ASQC Z1.4):

(a) Non-destructive Tests - General Inspection Level I. 

(b) Destructive Tests - Special Inspection Level S-2.

Specified Standards: The specified standards for the attributes requiring them shall be:

Attribute Specified Specified Standard

P-7 Type Quality and Uniformity Electronic Media

P-10. Process Color Match File Output

NOTE: Prior to award, contractor may be required to provide information related to specific equipment that will be used

for production.

OFFERS: Offers must include the cost of all materials and operations for the total quantity ordered in accordance with these

specifications. In addition, a price must be submitted for each additional one hundred pamphlets. The price ofthe 

additional quantities must be based on a continuing run, exclusive of all basic or preliminary charges (but will include

shipping), and will NOT be a factor for determination of award.

BID SUBMISSION: Bidders MUST submit email bids to bidssouthcentral@gpo.gov for this solicitation. No other 

method of bid submission will be accepted at this time.

The Jacket number (747-942) and bid opening date (August 23, 2023) must be specified in the subject line of the 

emailed bid submission. Bids received after the bid opening time/date specified above will not be considered for 

award.

NOTE: Bidders are to fill out, sign/initial, and return pages 8-9. 

ADDITIONAL EMAILED BID SUBMISSION PROVISIONS: The Government will not be responsible for any

failure attributable to the transmission or receipt of the emailed bid including, but not limited to, the following – 

1. Illegibility of bid.

2. Emails over 75 MB may not be received by GPO due to size limitations for receiving emails.

3. The bidder’s email provider may have different size limitations for sending email; however, bidders are advised not

to exceed GPO’s stated limit.

4. When the email bid is received by GPO, it will remain unopened until the specified bid opening time. Government

personnel will not validate receipt of the emailed bid prior to bid opening. GPO will use the prevailing time (specified

as the local time zone) and the exact time that the email is received by GPO’s email server as the official time stamp 

for bid receipt at the specified location.
Jackets 747-942 Page 7 of 9

PRE-AWARD SURVEY: In order to determine the responsibility of the prime contractor or any subcontractor, the

Government reserves the right to conduct an on-site preaward survey at the contractor's/subcontractor's facility or to

require other evidence of technical, production, managerial, financial, and similar abilities to perform, prior to the

award of a contract. As part of the financial determination, the contractor in line for award may be required to provideone

or more of the following financial documents:

1) Most recent profit and lossstatement

2) Most recent balance sheet

3) Statement of cash flows

4) Current official bank statement

5) Current lines of credit (with amounts available)

6) Letter of commitment from paper supplier(s)

7) Letter of commitment from any subcontractor

The documents will be reviewed to validate that adequate financial resources are available to perform the contract

requirements. Documents submitted will be kept confidential, and used only for the determination of responsibility by the

Government. Failure to provide the requested information in the time specified by the Government may result in the

Contracting Officer not having adequate information to reach an affirmative determination of responsibility.

PAYMENT: Submitting invoices for payment via the GPO fax gateway (if no samples are required) utilizing the GPO

barcode coversheet program application isthe most efficient method of receiving payment. Instruction for using this

method can be found at the following web address:

http://winapps.access.gpo.gov/fms/vouchers/barcode/instructions.html.

Invoices may also be mailed to: U.S. Government Publishing Office, Office of Financial Management, Attn: 

Comptroller, Stop: FMCE, Washington, DC 20401.

For more information about the billing process, refer to the General Information of the Office of Finance web page 

located at: https://www.gpo.gov/how-to-work-with-us/agency/billing-and-payment.
Jackets 747-942 Page 8 of 9 

CONTRACTOR: 

SHIPMENT(S): Shipments will be made from: City , State 

The city(ies) indicated above will be used for evaluation of transportation charges when shipmentf.o.b. contractor’s city 

is specified. If no shipping point is indicated above, it will be deemed that the bidder has selected the city and state shown

below in the address block, and the bid will be evaluated and the contract awarded on that basis. If shipment isnot made

from evaluation point, the contractor will be responsible for any additional shipping costs incurred.

Jacket: 747-942 Bid Price $ 

Additional rate per 1,000 Books: ____

DISCOUNTS: Discounts are offered for payment as follows: Percent, calendar days. See

Article 12 “Discounts” of Solicitation Provisions in GPO Contract Terms (Publication 310.2).

BID ACCEPTANCE PERIOD: In compliance with the above, the undersigned agree, if this bid is accepted within

calendar days (60 calendar days unless a different period is inserted by the bidder) from the date

for receipt of bids, to furnish the specified items at the price set opposite each item, delivered at the designated

points(s), in exact accordance with specifications.

NOTE: Failure to provide a 60-day bid acceptance period may result in expiration of the bid prior to award.

AMENDMENT(S): Bidder hereby acknowledges amendment(s) number(ed) 

________________

(Initials)

(COMPLETE AND SUBMIT THIS PAGE WITH YOUR BID)
Jackets 747-942 Page 9 of 9 

BIDDER’S NAME AND SIGNATURE: Unless specific written exception is taken, the bidder, by signing and

submitting a bid, agrees with and accepts responsibility for all certifications and representations as required by the

solicitation and GPO Contract Terms - Publication 310.2. When responding by fax or mail, fill out and return one copy of

pages 8 and 9, initialing/signing where indicated.

Failure to sign the signature block below may result in the bid being declared non-responsive.

 

(Contractor Name) (GPO Contractor’s Code)

(Street Address)

(City – State – Zip Code)

By 

(Printed Name, Signature, and Title of Person Authorized to Sign this Bid) (Date)

(Person to be Contacted) (Telephone Number) (Email)

** *****************************THIS SECTION FOR GPO USE ONLY****************************** 

Certified by: Contracting Officer: 

 (Initials and Date) (Initials and Date) 

**********************************************************************************************

(COMPLETE AND SUBMIT THIS PAGE WITH YOUR BID)
Product Number Name Quantity User Contact Name Company Name Address1 Address2 C

10050-LE Medicare & You 2024 (English Large Print) 1 Ms. Michelle Grochocinski

Wisconsin Department of Health Services 1 W Wilson St M

10050-LE Medicare & You 2024 (English Large Print) 1 Ms. Andrea R Sneller

Region VII Area Agency on Aging 1615 S Euclid Ave B

10050-LE Medicare & You 2024 (English Large Print) 1 Joseph Stone

CMS Boston Regional Office LEA 15 New Sudbury St Rm 2325 B

10050-LE Medicare & You 2024 (English Large Print) 1 Ms. Cristina Powell

Social Security Administration 507 Jewett St Ste B M

10050-LE Medicare & You 2024 (English Large Print) 1 Christine Griffin ServiceLink 2 Industrial Park Dr Ste 1 C10050-LE Medicare & You 2024 (English Large Print) 1 Mrs. Sheron Craig

Social Security Administration 800 Centrepark Dr A

10050-LE Medicare & You 2024 (English Large Print) 1 Ms. Shantel J Clark Weber Human Services 237 26th St Rm 320 O

10050-LE Medicare & You 2024 (English Large Print) 1 Jenny Hubert OCH 118 N Ozark Trl G

10050-LE Medicare & You 2024 (English Large Print) 1 Mrs. Hannah Larkin-Roelse ADRC-CW 220 3rd Ave S Ste 1 W

10050-LE Medicare & You 2024 (English Large Print) 1 Ms. Jean Horrocks MMAP Counselor 3091 N 7th St O10050-LE Medicare & You 2024 (English Large Print) 1 Geralyn Fortney

Area Agency on Aging Pasco/Pinellas Agi 9549 Koger Blvd N Ste 100 S

10050-LE Medicare & You 2024 (English Large Print) 1 Marlene McDaniel SHIP 710 N Opportunity Dr C10050-LE Medicare & You 2024 (English Large Print) 1 Ms. Kari J West The Senior Alliance 5454 Venoy Rd W

10050-LE Medicare & You 2024 (English Large Print) 1 Ms. Denise Joyce Medicare Counselor 2906 Alki Ave SW S

10050-LE Medicare & You 2024 (English Large Print) 1 Shelley Matson - ADRC

Aging & Disability Resource Center of Ve

402 Court House Square St V

10050-LE Medicare & You 2024 (English Large Print) 1 Ms. Katrina Nesmith Senior PharmAssist 406 Rigsbee Ave Ste 201 D10050-LE Medicare & You 2024 (English Large Print) 1 David Dennie Norfolk Public Library 235 E Plume St N

10050-LE Medicare & You 2024 (English Large Print) 1 Debi Ratliff

Rockbridge Regional Library 138 S Main St L

10050-LE Medicare & You 2024 (English Large Print) 1 Judi Young

Woodbridge Human Services 4 Meetinghouse Ln W

10050-LE Medicare & You 2024 (English Large Print) 1 Mrs. Lynn Hill

Putnam County Office for Aging 110 Old Route 6 Ste 1 C

10050-LE Medicare & You 2024 (English Large Print) 1 Nancy Wideman Lutheran Senior Services

11 Hilltop Village Center 

Dr E

10050-LE Medicare & You 2024 (English Large Print) 1 Danielle Minard

Comsewogue Public Library 170 Terryville Rd

PS

10050-LE Medicare & You 2024 (English Large Print) 1 Barb Wickman

Aging & Disability Resource Center of Ma 2500 Hall Ave M

10050-LE Medicare & You 2024 (English Large Print) 1 Ms. Leslie Pruitt

Agency on Aging of South Central CT 117 Washington Ave Ste 17 N

10050-LE Medicare & You 2024 (English Large Print) 1 Jessica Moxey

Montgomery County Health Department 11191 Illinois Route 185 H

10050-LE Medicare & You 2024 (English Large Print) 1 Mrs. Heather Noblin Madison Senior Services 29 Bradley Rd M10050-LE Medicare & You 2024 (English Large Print) 1 Rene Fannin

Green Lake County HHS/ADRC 571 County Road A G

10050-LE Medicare & You 2024 (English Large Print) 2 Mary Moran Upper Shore Aging,Inc 403 S 7th St Ste 127 D10050-LE Medicare & You 2024 (English Large Print) 2 Ms. Janet Boskill

Ks Department for Aging & Disability Srv 503 S Kansas Ave T

10050-LE Medicare & You 2024 (English Large Print) 2 Mrs. Rhonda K Hunter CMS - Atlanta

61 Forsyth Street, Suite 4-T-20 A

10050-LE Medicare & You 2024 (English Large Print) 2 Mary-Ann Reeter Lifelong 119 W Court St It10050-LE Medicare & You 2024 (English Large Print) 2 Idaho SHIBA

Idaho Department of Insurance 700 W State St 3rd Fl B

10050-LE Medicare & You 2024 (English Large Print) 2 Ms. Sarah Weilacher

Franklin County Office for the Aging 355 W Main St M

ATTACHMENT #1 747-942
10050-LE Medicare & You 2024 (English Large Print) 2 Ms. Angela Baker

Mount Prospect Public Library 10 S Emerson St M

10050-LE Medicare & You 2024 (English Large Print) 2 Mr. Sergio Trevin Verduzco

La Plata County Senior Center 2424 Main Ave D

10050-LE Medicare & You 2024 (English Large Print) 2 Mrs. Shalese Thomas

Prince George County Department of Famil 6420 Allentown Rd T

10050-LE Medicare & You 2024 (English Large Print) 2 Mrs. Mary Knapp SEKAAA 1225 130th Rd Y10050-LE Medicare & You 2024 (English Large Print) 2 Ms. Dana Thiesing Office For The Aging 50 Sanatorium Rd Bldg B P10050-LE Medicare & You 2024 (English Large Print) 2 Mr. Paul Benson Social Security Adm. 252 Venture Pl L10050-LE Medicare & You 2024 (English Large Print) 2 Ms. Crystal Behanna

Graham County Health Dept 225 N Pomeroy Ave H

10050-LE Medicare & You 2024 (English Large Print) 2 Hanna Hall

Warren Hamilton Counties Office for the 1340 State Route 9 L

10050-LE Medicare & You 2024 (English Large Print) 2 Stefan Goslawski Apprise 4422 Walbert Ave A10050-LE Medicare & You 2024 (English Large Print) 3 Mrs. Karen Wood

Diakon Community Services for Seniors 2020 W Norwegian St P

10050-LE Medicare & You 2024 (English Large Print) 3 Ronald Fitzgerald Moore

Centers for Medicare and Medicaid Servic 701 5th Ave Ste 1700 S

10050-LE Medicare & You 2024 (English Large Print) 3 Aging Resource Center

Aging and Disablity Resorce Center 206 Court St C

10050-LE Medicare & You 2024 (English Large Print) 3 Rebekah Greenwood NWCO Medicare SHIP 775 Yampa Ave C10050-LE Medicare & You 2024 (English Large Print) 3 Ms. Mary Kempf ADRC 650 Forest Ave S10050-LE Medicare & You 2024 (English Large Print) 4 Caitlin Milleer HICAP-IE 2280 Market St Ste 140 R10050-LE Medicare & You 2024 (English Large Print) 4 Mrs. Sandy Bishop

Marshall County Council on Aging 436 Blount Ave G

10050-LE Medicare & You 2024 (English Large Print) 5 Brian Other (Specify) Hollins

Challenges, Options in Aging 2706 Mercer Rd N

10050-LE Medicare & You 2024 (English Large Print) 5 AMY EGGLETON

Social Security Administration

1840 Jake Alexander Blvd W S

10050-LE Medicare & You 2024 (English Large Print) 5 Ms. Janet Vandeusen

Legal Assistance for Seniors 333 Hegenberger Rd Ste 850 O

10050-LE Medicare & You 2024 (English Large Print) 5 Ms. Jo Escue SHIP 613 College Street Rd E10050-LE Medicare & You 2024 (English Large Print) 5 Pocatello SHIBA

Idaho Department of Insurance 353 N 4th Ave Ste 200 P

10050-LE Medicare & You 2024 (English Large Print) 5 Mr. Michael L Dawkins NC DOI SHIIP 325 N Salisbury St R10050-LE Medicare & You 2024 (English Large Print) 5 Susan B Hackney

United Way Area Agency on Aging 3600 8th Ave S B

10050-LE Medicare & You 2024 (English Large Print) 5 Ms. Antoinette Gardner GA SHIP 761 Wheaton St S10050-LE Medicare & You 2024 (English Large Print) 5 Ms. Kathryn Lopan

State of Nevada SHIP/SMP/MIPPA 3320 W Sahara Ave Ste 100 L

10050-LE Medicare & You 2024 (English Large Print) 5 Terri Esselman Clark County ADRC 517 Court St Rm 201 N10050-LE Medicare & You 2024 (English Large Print) 5 Emma Borck ADRC of Jefferson County 1541 Annex Rd Je10050-LE Medicare & You 2024 (English Large Print) 5 Ms. Michelle Robinson

Mercer County Senior Center 137 W Main St A

10050-LE Medicare & You 2024 (English Large Print) 5 Becky McIntyre UP Area Agency on Aging 2501 14th Ave S E10050-LE Medicare & You 2024 (English Large Print) 5 Andrea Dickson Wixom Public Library 49015 Pontiac Trl W10050-LE Medicare & You 2024 (English Large Print) 5 Mary Elizabeth Taylor

Braxton County Senior Citizens Center 23 Senior Center Dr S

10050-LE Medicare & You 2024 (English Large Print) 5 Debbie Geiman Country Club Tower 1515 Clubhouse Dr 4th Fl A10050-LE Medicare & You 2024 (English Large Print) 5 Ms. Deborah L Wills

Hawaii County Office of Aging

74-5044 Ane Keohokalole Hwy Bldg B K

10050-LE Medicare & You 2024 (English Large Print) 5 Jan Williamson Roscommon COA 1015 Short Dr Ste A P
10050-LE Medicare & You 2024 (English Large Print) 5 Ms. Julie Posada

Central Coast Comm for Sr Citizens 528 S Broadway S

10050-LE Medicare & You 2024 (English Large Print) 5 Shara Bastian Six County AOG 250 N Main St B3 R10050-LE Medicare & You 2024 (English Large Print) 5 Rachel Wright

Greene County Human Services 411 Main St Ste 247 C

10050-LE Medicare & You 2024 (English Large Print) 5 Billi Charron

Princeton Senior Resource Center 101 Poor Farm Rd Ste 2 P

10050-LE Medicare & You 2024 (English Large Print) 5 Molly Sanderson

North Central-Flint Hills Area Agency on 401 Houston St M

10050-LE Medicare & You 2024 (English Large Print) 5 Mrs. Judy Crawford

Area Agency on Aging of North Texas

4309 Old Jacksboro Hwy Ste 200 W

10050-LE Medicare & You 2024 (English Large Print) 5 Cathy Holley

ERBA Crawford Sr. Center 300 S Lincoln St R

10050-LE Medicare & You 2024 (English Large Print) 5 Ms. Jacky Robinson

Bicentennial Manor/Key Management Compan 1010 W 8th St Ju

10050-LE Medicare & You 2024 (English Large Print) 6 Barbara Elizabeth Krueger Deer Park Public Library 112 Front St W D10050-LE Medicare & You 2024 (English Large Print) 6 Mr. Michael H Cober Area Agency On Aging 240 S Wood St B10050-LE Medicare & You 2024 (English Large Print) 8 Christine Hyland

Santa Clara County Library 1370 Dell Ave 1370 Dell Ave C

10050-LE Medicare & You 2024 (English Large Print) 8 Bettina Rinard

Aging and Disability Resource Center of 2600 Stewart Ave Ste 25 W

10050-LE Medicare & You 2024 (English Large Print) 10 Mrs. Paula Silva

Harris County Area Agency on Aging 9250 Kirby Dr H

10050-LE Medicare & You 2024 (English Large Print) 10 Rentha Person AB Your Choice Insurance 5515 W Libby St G10050-LE Medicare & You 2024 (English Large Print) 10 Ms. Toni Browning

Rappahannock Rapidan Community Services 15361 Bradford Rd C

10050-LE Medicare & You 2024 (English Large Print) 10 CDA IDAHO SHIBA

Idaho Department of Insurance 2005 N Ironwood Pkwy Ste 143 C

10050-LE Medicare & You 2024 (English Large Print) 10 Alyse Bergersen Independence Northwest 1183 New Haven Rd Ste 4 N10050-LE Medicare & You 2024 (English Large Print) 10 Ms. Megan Delores Gerardy Jackson County ADRC 421 County Road R B10050-LE Medicare & You 2024 (English Large Print) 10 Jeanne Larson AK SHIP 1835 Bragaw St Ste 350 A10050-LE Medicare & You 2024 (English Large Print) 10 Loni Hitchcock UCDD 1104 England Dr C10050-LE Medicare & You 2024 (English Large Print) 10 Mrs. Lora Bell

Tooele County Aging Services 151 N Main St Ste 140 T

10050-LE Medicare & You 2024 (English Large Print) 10 Mrs. Becky Faulk Commission on Aging

1539 Sportsman Lake Rd NW C

10050-LE Medicare & You 2024 (English Large Print) 10 Mrs. Kimberly Haun Swan 832 W North Ave Ste B F10050-LE Medicare & You 2024 (English Large Print) 10 Mr. George Lutz Levittown Public Library 1 Bluegrass Ln L10050-LE Medicare & You 2024 (English Large Print) 10 Carrie Davis Covenant Woods

7090 Covenant Woods Dr M

10050-LE Medicare & You 2024 (English Large Print) 10 Mrs. Diane Jolly

Social Security Administration 5020 W North Ave M

10050-LE Medicare & You 2024 (English Large Print) 10 Mr. Anthony Ruiz

Redding Rancheria Tribal Health System 2775 Bechelli Ln R

10050-LE Medicare & You 2024 (English Large Print) 10 Mrs. Stephanie Fultz

CICOA Aging & In-Home Solutions

8440 Woodfield Crossing Blvd Ste 175 In

10050-LE Medicare & You 2024 (English Large Print) 10 Mrs. SONIA S VAUGHN

Ventura County Area Agency on Aging 646 County Square Dr V

10050-LE Medicare & You 2024 (English Large Print) 10 Ms. Cathy A Bond Bear River Health 2329 Center St B10050-LE Medicare & You 2024 (English Large Print) 12 Emma Wilson

Social Security Administration 710 Alabama St B

10050-LE Medicare & You 2024 (English Large Print) 15 Ms. Elaine M Palmer Social Security 901 University Dr Ste 2 S
10050-LE Medicare & You 2024 (English Large Print) 15 Nina Yang

Milwaukee County Area Agency on Aging 1220 W Vliet St Ste 300 M

10050-LE Medicare & You 2024 (English Large Print) 15 Pam Lovera

Fauquier County Public Library 11 Winchester St W

10050-LE Medicare & You 2024 (English Large Print) 15 Barb Templeman

Extension Library District of Huron Coun 6 W Emerald St W

10050-LE Medicare & You 2024 (English Large Print) 15 Michael Moldoye Opportunity Council 1419 Cornwall Ave B10050-LE Medicare & You 2024 (English Large Print) 20 Annette Barca SHIBA -Whidbey Island 14594 State Route 525 La10050-LE Medicare & You 2024 (English Large Print) 20

Belinda Willingham SHIP/DACL

SHIP/DACL Attn Belinda Willingham 250 E St SW 6th Fl W

10050-LE Medicare & You 2024 (English Large Print) 20 Ann Marie Megoulas

Dauphin County Library System 4501 Ethel St H

10050-LE Medicare & You 2024 (English Large Print) 20 Lauren Rossi Old Bridge Public Library 1 Old Bridge Plz O10050-LE Medicare & You 2024 (English Large Print) 20 Ms. Michelle Thomas Arlington County 2100 Washington Blvd Fl 4 A10050-LE Medicare & You 2024 (English Large Print) 20 Stephanie Hood Lifetime Resources 13091 Benedict Dr D10050-LE Medicare & You 2024 (English Large Print) 20 Ms. Joan Newton

Leon Mathieu Senior Center 420 Main St 2nd Fl P

10050-LE Medicare & You 2024 (English Large Print) 20 Christinna Swearingen

Rusk County Community Library 418 Corbett Ave W L

10050-LE Medicare & You 2024 (English Large Print) 20 Nita Ford

Lafourche Council on Aging 238 Bowie Road R

10050-LE Medicare & You 2024 (English Large Print) 20 Mr. Daniel Herman Social Security Admin 501 E Bender Blvd H10050-LE Medicare & You 2024 (English Large Print) 20 Mr. Darryl Kalich SSA 927 S Highway 123 Byp S10050-LE Medicare & You 2024 (English Large Print) 20 Robin Eubank-Callis

K-State Research & Extension 118 E Washington Ave M

10050-LE Medicare & You 2024 (English Large Print) 20 Catherine Folk-Pushee Johnson Public Library 275 Moore St H10050-LE Medicare & You 2024 (English Large Print) 20 Becky Rostron

ServiceLink Resource Center of Sullivan 180 Twistback Rd C

10050-LE Medicare & You 2024 (English Large Print) 25 Mr. John Henry Crippen Multnomah County 209 SW 4th Ave Ste 510 P10050-LE Medicare & You 2024 (English Large Print) 25 Ms. Jamie Her ADRC of Dane County 2865 N Sherman Ave M10050-LE Medicare & You 2024 (English Large Print) 25 Taylor Thorn SHIBA 1400 Queen Ave SE Ste 102 A10050-LE Medicare & You 2024 (English Large Print) 25 Mr. Michael Perlman Island Park Public Library 176 Long Beach Rd Is10050-LE Medicare & You 2024 (English Large Print) 25 Rachel O'Carroll Experience, Inc. 905 4th Ave W10050-LE Medicare & You 2024 (English Large Print) 25 Ms. Charlotte E McNeely LSCOG 2748 Wagener Rd A10050-LE Medicare & You 2024 (English Large Print) 25 Ms. Maureen M McCarthy

Strafford County ServiceLink 25 Old Dover Rd R

10050-LE Medicare & You 2024 (English Large Print) 25 Cheryl Morelli

Social Security Administration 636 Pine St M

10050-LE Medicare & You 2024 (English Large Print) 25 Mrs. Yonette Backer

Social Security Administration 785 Flushing Ave Fl 3 B

10050-LE Medicare & You 2024 (English Large Print) 25 Jenifer J Grace etowah council on aging 623 Broad St G10050-LE Medicare & You 2024 (English Large Print) 25 Kelly Ott

Children's Home Society of NJ 635 S Clinton Ave T

10050-LE Medicare & You 2024 (English Large Print) 25 Annie R Nersten Upper Skagit Indian Tribe

25959 Community Plaza Way S

10050-LE Medicare & You 2024 (English Large Print) 25 Beth Miller Monmouth County Library 1001 Broad Street S10050-LE Medicare & You 2024 (English Large Print) 25

Mrs. DEBORAH FITZGERALD

AREA AGENCY ON AGING, SWA 600 Lelia M

10050-LE Medicare & You 2024 (English Large Print) 25 Ms. Phyllis Donley

Arkansas Insurance Department 1 Commerce Way L

10050-LE Medicare & You 2024 (English Large Print) 30 Ms. Pamela Gatlin

Area Agency of Aging of SWAR 600 Lelia M

10050-LE Medicare & You 2024 (English Large Print) 30 Mr. Jay Daniel Stephens Legacy Link Inc 4080 Mundy Mill Rd O
10050-LE Medicare & You 2024 (English Large Print) 30 Mrs. Elanya Bairefoot Palm Bay Public Library

1520 Port Malabar Blvd NE P

10050-LE Medicare & You 2024 (English Large Print) 40 Ms. Vivian D-King ACMS 160 N Main St 3rd Fl M10050-LE Medicare & You 2024 (English Large Print) 40 Ms. Christine R Sarracino

Pueblo of Laguna Benefits 

Services Progr PO Box 194 L

10050-LE Medicare & You 2024 (English Large Print) 50 Sarah Nelson City of Grand Prairie 901 Conover Dr G10050-LE Medicare & You 2024 (English Large Print) 50 Mrs. Rebecca Townsend

Social Security Administration 6553 Winford Ave

FT

10050-LE Medicare & You 2024 (English Large Print) 50 Mr. David Dennewitz

Social Security Administration 550 Main St Ste 2000 C

10050-LE Medicare & You 2024 (English Large Print) 50 Debra Rosner

Margaret E. Heggan Free Public Library 606 Delsea Dr S

10050-LE Medicare & You 2024 (English Large Print) 50 Ms. Rosalind Jones

East Central Planning and Development Di 280 Commercial Dr N

10050-LE Medicare & You 2024 (English Large Print) 50 Mrs. Gail S Spiewak

Chowan County Cooperative Extension 730 N Granville St Ste A E

10050-LE Medicare & You 2024 (English Large Print) 50 Mrs. Bridgette Roark-Sample

Kansas/Missouri Liscensed Health and Lif 8600 Haskell Ave K

10050-LE Medicare & You 2024 (English Large Print) 70 Amanda Marvin BCLS 500 Center Ave B10050-LE Medicare & You 2024 (English Large Print) 100 Ms. Glenda Radical

Senior Community Services 1515 Lansdowne Ave D

10050-LE Medicare & You 2024 (English Large Print) 100 Frank Winter CMS 26 Federal Plz Fl 18 N10050-LE Medicare & You 2024 (English Large Print) 100 Jillian McKeown WIlmette Public Library 1242 Wilmette Ave W10050-LE Medicare & You 2024 (English Large Print) 100 Olivia Jones

Knoxville Area Project Access 9032 Cross Park Dr K

10050-LE Medicare & You 2024 (English Large Print) 100 Erin Thompson SSA 4 Seagate Ste 1000 T10050-LE Medicare & You 2024 (English Large Print) 100 Ardyce Mercier SETAAAD 1000 Riverfront Pkwy C10050-LE Medicare & You 2024 (English Large Print) 150 Ms. Kennedy Mengerink

Social Security Administration 401 W North St Ste 101 L

10050-LE Medicare & You 2024 (English Large Print) 150 Lynn Bolmer Woodbridge Public Library 1G Frederick Plaza W10050-LE Medicare & You 2024 (English Large Print) 200 Mrs. Emily Dovermann Hawaii State Library 478 S King St

Hawaii State Library - Federal Documents H

10050-LE Medicare & You 2024 (English Large Print) 200 Charlotte Hena Pueblo of Tesuque 20 TP828 S10050-LE Medicare & You 2024 (English Large Print) 500 Ms. KIMBERLY SIMON SSA 5455 Bankers Ave B10050-LE Medicare & You 2024 (English Large Print) 1000 Attn: PODFO

United Systems of Arkansas, Inc. 4949 West Bethany Rd L

10050-LE Medicare & You 2024 (English Large Print) 2500 Receiving Clerk CMS 7500 Security Blvd B

7,050
 PRIVACY ACT 

(a) The contractor agrees:

(1) to comply with the Privacy Act of l974 and the rules and regulations issued pursuant to the Act

in the design, development, or operation of any system of records on individuals in order to accomplish an 

agency function when the contract specifically identifies (i) the system or systems of records and (ii) the 

work to be performed by the contractor in terms of any one or combination of the following: (A) design, 

(B) development, or (C) operation;

(2) to include the solicitation notification contained in this contract in every solicitation and resulting

subcontract and in every subcontract awarded without a solicitation when the statement of work in the 

proposed subcontract requires the design, development, or operation of a system of records on individuals 

to accomplish an agency function; and 

(3) to include this clause, including this paragraph (3), in all subcontracts awarded pursuant to this

contract which require the design, development, or operation of such a system of records. 

(b) In the event of violations of the Act, a civil action may be brought against the agency involved where

the violation concerns the design, development, or operation of a system of records on individuals to accomplish an 

agency function, and criminal penalties may be imposed upon the officers or employees of the agency where the 

violation concerns the operation of a system of records on individuals to accomplish an agency function. For 

purposes of the Act when the contract is for the operation of a system of records on individuals to accomplish an 

agency function, the contractor and any employee of the contractor is considered to be an employee of the agency. 

(c) The terms used in this clause have the following meanings:

(1) "Operation of a system of records" means performance of any of the activities associated with

maintaining the system of records including the collection, use, and dissemination of records. 

(2) "Record" means any item, collection or grouping of information about an individual that is

maintained by an agency, including, but not limited to, his education, financial transactions, medical 

history, and criminal or employment history and that contains his name, or the identifying number, symbol, 

or other identifying particular assigned to the individual, such as a finger or voice print or a photograph. 

(3) "System of records" on individuals means a group of any records under the control of any

agency from which information is retrieved by the name of the individual or by some identifying number, 

symbol, or other identifying particular assigned to the individual. 

Additional information regarding the CMS EFT Infrastructure can be found at the following link: 

http://www.cms.hhs.gov/SystemLifecycleFramework/Downloads/EFTInfrastructure.pdf

Software: Contractor will need Internet browser, the browser must be Internet Explorer 5.0 or above, or you can use 

GIS-compatible secure File Transfer Protocol Client (FTP). 

The contractor must provide all mailing materials, as well as all labeling and marking, as necessary to fulfill mailing 

and distribution requirements. Noncompliance with the packing and labeling instructions will be cause for the 

Government to take corrective action in accordance with GPO Pub. 310.2. 

Attachment #2 Jacket 747-942

1 of 32 Jacket 747-942 Attach 2, Exhibits A - H - CMS Security Requirements
Exhibit A 

CMS CLAUSE 11: CMS INFORMATION SECURITY 

PAGE 1 OF 2 

2 of 32 Jacket 747-942 Attach 2, Exhibits A - H - CMS Security Requirements
EXHIBIT A 

CMS CLAUSE 11: CMS INFORMATION SECURITY 

PAGE 2 OF 2 

3 of 32 Jacket 747-942 Attach 2, Exhibits A - H - CMS Security Requirements
EXHIBIT B 

CMS CLAUSE 09A-01 SECURITY CLAUSE 

PAGE 1 OF 5 

4 of 32 Jacket 747-942 Attach 2, Exhibits A - H - CMS Security Requirements
EXHIBIT B 

CMS CLAUSE 09A-01 SECURITY CLAUSE 

PAGE 2 OF 5 

5 of 32 Jacket 747-942 Attach 2, Exhibits A - H - CMS Security Requirements
EXHIBIT B 

CMS CLAUSE 09A-01 SECURITY CLAUSE 

PAGE 3 OF 5 

6 of 32 Jacket 747-942 Attach 2, Exhibits A - H - CMS Security Requirements
EXHIBIT B 

CMS CLAUSE 09A-01 SECURITY CLAUSE 

PAGE 4 OF 5 

7 of 32 Jacket 747-942 Attach 2, Exhibits A - H - CMS Security Requirements
EXHIBIT B 

CMS CLAUSE 09A-01 SECURITY CLAUSE 

PAGE 5 OF 5 

8 of 32 Jacket 747-942 Attach 2, Exhibits A - H - CMS Security Requirements
EXHIBIT C 

FAQ SUPPLEMENT TO CMS SECURITY CLAUSE 09A-01 

PAGE 1 OF 3 

9 of 32 Jacket 747-942 Attach 2, Exhibits A - H - CMS Security Requirements
EXHIBIT C 

FAQ SUPPLEMENT TO CMS SECURITY CLAUSE 09A-01 

PAGE 2 OF 3 

10 of 32 Jacket 747-942 Attach 2, Exhibits A - H - CMS Security Requirements
EXHIBIT C 

FAQ SUPPLEMENT TO CMS SECURITY CLAUSE 09A-01 

PAGE 3 OF 3 

11 of 32 Jacket 747-942 Attach 2, Exhibits A - H - CMS Security Requirements
EXHIBIT D HHS Identification (ID) Badge Request HHS-Form 745 (5/07) Page 1 of 6

12 of 32 Jacket 747-942 Attach 2, Exhibits A - H - CMS Security Requirements
EXHIBIT D HHS Identification (ID) Badge Request HHS-Form 745 (5/07) Page 2 of 6

13 of 32 Jacket 747-942 Attach 2, Exhibits A - H - CMS Security Requirements
EXHIBIT D HHS Identification (ID) Badge Request HHS-Form 745 (5/07) Page 3 of 6 

14 of 32 Jacket 747-942 Attach 2, Exhibits A - H - CMS Security Requirements
EXHIBIT D HHS Identification (ID) Badge Request HHS-Form 745 (5/07) Page 4 of 6 

15 of 32 Jacket 747-942 Attach 2, Exhibits A - H - CMS Security Requirements
EXHIBIT D HHS Identification (ID) Badge Request HHS-Form 745 (5/07) Page 5 of 6

16 of 32 Jacket 747-942 Attach 2, Exhibits A - H - CMS Security Requirements
EXHIBIT D HHS Identification (ID) Badge Request HHS-Form 745 (5/07) Page 6 of 6 

17 of 32 Jacket 747-942 Attach 2, Exhibits A - H - CMS Security Requirements
EXHIBIT E 

APPLICATION FOR ACCESS TO CMS COMPUTER SYSTEMS (FORM CMS-20037) 

PAGE 1 OF 3 

18 of 32 Jacket 747-942 Attach 2, Exhibits A - H - CMS Security Requirements
EXHIBIT E 

APPLICATION FOR ACCESS TO CMS COMPUTER SYSTEMS (FORM CMS-20037) 

PAGE 2 OF 3 

19 of 32 Jacket 747-942 Attach 2, Exhibits A - H - CMS Security Requirements
EXHIBIT E 

APPLICATION FOR ACCESS TO CMS COMPUTER SYSTEMS (FORM CMS-20037) 

PAGE 3 OF 3 

20 of 32 Jacket 747-942 Attach 2, Exhibits A - H - CMS Security Requirements
EXHIBIT F 

DATA USE AGREEMENT (DUA) (FORM CMS-R-0235) 

PAGE 1 OF 6 

21 of 32 Jacket 747-942 Attach 2, Exhibits A - H - CMS Security Requirements
EXHIBIT F 

DATA USE AGREEMENT (DUA) (FORM CMS-R-0235) 

PAGE 2 OF 6 

22 of 32 Jacket 747-942 Attach 2, Exhibits A - H - CMS Security Requirements
EXHIBIT F 

DATA USE AGREEMENT (DUA) (FORM CMS-R-0235) 

PAGE 3 OF 6 

23 of 32 Jacket 747-942 Attach 2, Exhibits A - H - CMS Security Requirements
EXHIBIT F 

DATA USE AGREEMENT (DUA) (FORM CMS-R-0235) 

PAGE 4 OF 6 

24 of 32 Jacket 747-942 Attach 2, Exhibits A - H - CMS Security Requirements
EXHIBIT F 

DATA USE AGREEMENT (DUA) (FORM CMS-R-0235) 

PAGE 5 OF 6 

25 of 32 Jacket 747-942 Attach 2, Exhibits A - H - CMS Security Requirements
EXHIBIT F 

DATA USE AGREEMENT (DUA) (FORM CMS-R-0235) 

PAGE 6 OF 6 

26 of 32 Jacket 747-942 Attach 2, Exhibits A - H - CMS Security Requirements
EXHIBIT G 

CERTIFICATE OF DATA DESTRUCTION (FORM CMS-10252) 

PAGE 1 OF 2 

27 of 32 Jacket 747-942 Attach 2, Exhibits A - H - CMS Security Requirements
EXHIBIT G 

CERTIFICATE OF DATA DESTRUCTION (FORM CMS-10252) 

PAGE 2 OF 2 

28 of 32 Jacket 747-942 Attach 2, Exhibits A - H - CMS Security Requirements
EXHIBIT H 

SECURE ONE HHS, INFORMATION SECURITY PROGRAM RULES OF BEHAVIOR 

PAGE 1 OF 4 

29 of 32 Jacket 747-942 Attach 2, Exhibits A - H - CMS Security Requirements
EXHIBIT H 

SECURE ONE HHS, INFORMATION SECURITY PROGRAM RULES OF BEHAVIOR 

PAGE 2 OF 4 

30 of 32 Jacket 747-942 Attach 2, Exhibits A - H - CMS Security Requirements
EXHIBIT H 

SECURE ONE HHS, INFORMATION SECURITY PROGRAM RULES OF BEHAVIOR 

PAGE 3 OF 4 

31 of 32 Jacket 747-942 Attach 2, Exhibits A - H - CMS Security Requirements
EXHIBIT H 

SECURE ONE HHS, INFORMATION SECURITY PROGRAM RULES OF BEHAVIOR 

PAGE 4 OF 4 

32 of 32 Jacket 747-942 Attach 2, Exhibits A - H - CMS Security Requirements