Defense Security Service Industrial Security Review Data and Defense Security Service Industrial Security Facility Clearance Survey Data

OMB Approval Date:

OMB No: 0704-0427

Expiration Date:

DEFENSE SECURITY SERVICE

INDUSTRIAL SECURITY FACILITY CLEARANCE SURVEY DATA

Agency Disclosure Notice

Public reporting burden for this collection of information is estimated to average 2 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the Department of Defense, Washington Headquarters Services, Directorate for Information Operations and Reports (OMB NO. 0704-0427), 1215 Jefferson Davis Highway, Suite 1204, Arlington, VA 22202-4302. Respondents should be aware that not withstanding any other provision of law, no person shall be subject to any penalty for failing to comply with this collection of information if it does not display a currently valid OMB control number. Please do not return your response to the above address.

Privacy Act Statement

Authority: 50 USC, Sections 781– 887, “Internal Security Act of 1950;” Executive Order (EO) 9397, “Numbering System for Federal Accounts Relating to Individuals,” November 22, 1943; EO 10865, “Safeguarding Classified Information Within Industry,” February 20, 1960 as amended by EO 10909, January 16, 1961 and EO 11382, November 27, 1967; EO 11935, “Citizenship Requirements for Federal Employment;” EO 12333, “United States Intelligence Activities,” December 8, 1981; EO 12656, “Assignment of Emergency Preparedness Responsibilities,” November 18, 1988; EO 12829, “National Industrial Security Program,” January 6, 1993 as amended by E.O. 12885, December 14, 1993; EO 12958, “Classified National Security Information,” April 17, 1995, as amended March 25, 2003 and 5 USC Section 301, “Department Regulations.”

Principle Purpose(s): To obtain preliminary information for facility and personnel security clearance eligibility determinations. Utilized for evaluative purposes to allow access to classified information, sensitive areas, or equipment, or to permit assignment to sensitive national security positions. The data may later be used as part of a security review process to evaluate continued eligibility for access to classified information. The Social Security Number will be used to verify, identify and locate existing records.

Attachment 2-3

Routine Use(s): Provided to federal, state or local government agencies if necessary to

obtain information for a personnel security clearance, or making a security determination

concerning retention in a sensitive position, or letting a contract. May be provided to a congressional office in response to an inquiry made at the request of the individual, or to foreign or domestic law enforcement, security, investigative, or administrative authorities to comply with domestic and/or international agreements. Provided to the Department of Justice in pending or potential litigation to which the record is pertinent. For records management purposes data may be provided to the General Services Administration; and National Archives and Records Administration. Data may also be disclosed for counterintelligence activities authorized by Federal Law or Executive Order, within and outside the DoD or the U.S. Government.

Disclosure: Voluntary; however, failure to furnish the requested information may result in our being unable to issue the contractor a Facility Security Clearance (FCL).

DEFENSE SECURITY SERVICE

INDUSTRIAL SECURITY FACILITY CLEARANCE SURVEY DATA

As a result of the initial Facility Survey DSS shall retain information pertaining to the FCL and safeguarding capability for a period of two years after termination of the FCL. All information gathered shall be marked and handled as “For Official Use Only” and/or with a classification marking, as appropriate.

1.1. Information to be maintained includes, but is not limited to:

1.1.1. Basic FCL and storage capability information:

1.1.1.2. Contractor’s legal name.

1.1.1.3. Contractor’s alias names.

1.1.1.4. Contractor and Government Entity (CAGE) code.

1.1.1.5. Physical addresses (present and over previous 10 years).

1.1.1.6. Unclassified mailing address.

1.1.1.7. Classified and/or overnight delivery address, as appropriate.

1.1.1.8. Facility Security Officer (FSO) name.

1.1.1.9. Phone number/e-mail address.

1.1.1.10. FCL level.

1.1.1.11. FCL date (Interim/Final).

1.1.1.12. Approved storage capability and level.

1.1.1.13. Special access categories.

1.1.1.14. Key Management Personnel (KMP), Principle Stockholder and Negotiators identifying information.

1.1.1.14.1. Name.

1.1.1.14.2. Title.

1.1.1.14.3. Social Security Number.

4. Date and place of birth.

5. Personnel Security Clearance status.

6. Citizenship.

7. Percentage of stock owned, as appropriate.

1.1.1.15. Parent/Home Office (HOF)/Principle Management Facility (PMF) information, if applicable.

1.1.1.16. Approved off-site locations, if applicable.

1.1.1.17. Name and address changes during the past 10 years (includes from and to year, month and day).

1.2.1. Type of business.

1.2.2. Business/Legal structure.

1.2.2.1. State of incorporation, date of incorporation and type of corporation, if applicable.

1.2.2.2. Officer positions provided by By-Laws and positions currently established.

1.2.2.3. Number of Directors currently authorized by By-Laws or Articles of Incorporation.

1.2.2.4. Number of Directors currently elected.

1.2.2.5. Provisions for a Rotating or Pro-tem Chairman of the Board or Executive Committee.

1.2.2.6. Amount of common stock authorized and issued.

1.2.2.7. Amount of preferred stock authorized and issued.

1.2.3. Contract/subcontract information.

1.2.4. Foreign Ownership Control or Influence (FOCI) mitigation instrument, if applicable.

1.2.4.1. Foreign Interests ownership or beneficial ownership of organizational securities.

1.2.4.1.1. Name of company or individual.

1.2.4.1.2. Address.

1.2.4.1.3. Percentage of securities owned.

1.3.1 Number of employees.

1.3.1.1. Number of cleared employees by clearance level.

1.3.1.2. Number of cleared employees assigned to uncleared locations.

3. Numbers and types of Limited Access Authorizations.

3. Numbers and types of Non-U.S. citizens.

1.4.1. International involvement.

1.4.1.1. Foreign contract information.

1.4.1.2. Export authorizations.

1.4.1.3. Foreign Military Sales (FMS).

1.4.1.4. Foreign Government Information (FGI).

1.4.1.5. Program/Project Security Instructions.

1.4.1.6. Foreign visitors as they pertain to technology control plans and access to classified requirements.

1.4.1.7. Employees at overseas locations.

1.5.1. Special Programs.

1.6.1. Other special requirements imposed by the Government Contracting Agency(s) on the contractor.