Form BIS Form 999 BIS Form 999 Request for Special Priorities Assistance

FORM BIS-999
REV. X-23

U.S. DEPARTMENT OF COMMERCE
BUREAU OF INDUSTRY AND SECURITY

REQUEST FOR SPECIAL PRIORITIES ASSISTANCE

FOR DOC USE

OMB NO. 0694-0057

CASE NO. ______________________________
RECEIVED _____________________________

READ INSTRUCTIONS ON LAST PAGE

ASSIGNED TO __________________________

Submission of a completed application is required to request Special Priorities Assistance (SPA). See sections 700.50-58 of the Defense Priorities and Allocations
System (DPAS) regulation (15 CFR 700). It is a criminal offense under 18 U.S.C. 1001 to make a willfully false statement or representation to any U.S.
Government agency as to any matter within its jurisdiction. All company information furnished related to this application will be deemed BUSINESS
CONFIDENTIAL under sec. 705(d) of the Defense Production Act of 1950 (50 U.S.C. § 4555(d)) which prohibits publication or disclosure of this information
unless the President determines that withholding it is contrary to the interest of the national defense. The Department of Commerce will assert the appropriate
Freedom of Information Act (FOIA) exemptions if such information is the subject of FOIA requests. The unauthorized publication or disclosure of such
information by Government personnel is prohibited by law. Violators are subject to fine and/or imprisonment.
1.

APPLICANT INFORMATION

a. Name and complete address of Applicant (Applicant can be any person
needing assistance - Government agency, contractor, or supplier. See
definition of "Applicant" in Footnotes section on last page of this form).
Applicant Name _________________________________________________
Address________________________________________________________
City______________________State ________________Zip______________
Country________________________________________________________
Contact's name__________________________________________________
Title___________________________________________________________
Telephone_________________________ Fax_________________________
E-mail address_________________________________________________

b. If Applicant is not end-user Government agency, give name and
complete address of Applicant's customer.
Customer Name _________________________________________________
Address_______________________________ City_____________________
State _______________ Zip______________ Country__________________
Contact's name __________________________________________________
Title ___________________________ Telephone ______________________
E-mail address________________________ FAX _____________________
Contract/purchase order no. ________________________________________
Dated ______________________ Priority rating ______________________

2. APPLICANT ITEM(S). If Applicant is not end-user Government agency, describe item(s) to be delivered by Applicant under its customer's contract or
purchase order through the use of item(s) listed in Block 3. If known, identify Government program and end-item for which these items are required. If Applicant
is end-user Government agency and Block 3 item(s) are not end-items, identify the end-item for which the Block 3 item(s) are required. See definition of "item" in
Footnotes section on last page of this form.

3.

ITEM(S) (including service) FOR WHICH APPLICANT REQUESTS ASSISTANCE
Quantity
Pieces, units

Description

Include identifying information such as model or part number and manufacturer

Dollar Value
Each quantity listed

4.

SUPPLIER INFORMATION

a. Name and complete address of Applicant's Supplier.

b. Applicant's contract or purchase order to Supplier.

Supplier Name __________________________________________________
Number _______________________________________________________
Address______________________________ City______________________
State ________________ Zip______________ Country__________________
Contact Name ___________________________________________________
Title ___________________________________________________________
Telephone_ ________________________ Fax_________________________

Dated _________________________________________________________
Priority rating __________________________________________________
(If none, so state)
If Supplier is an agent or distributor, give complete producer or lower
tier supplier information in Continuation Block on page 3, including
purchase order number, date, and priority rating (if none, so state).

E-mail address: __________________________________________________
5.

SHIPMENT SCHEDULE OF ITEM(S) SHOWN IN BLOCK 3

a. Applicant's original
shipment/performance
requirement

Month
Year

Total
units

Number of
units
b. Supplier's original
shipment/performance
promise

Month
Year

Total
units

Number of
units
c. Applicant's current
shipment/performance
requirement

Month
Year

Total
units

Number of
units
d. Supplier's current
shipment/performance
promise

Month
Year

Total
units

Number of
units
6.

7.

REASONS GIVEN BY SUPPLIER for inability to meet Applicant's required shipment or performance date(s).

BRIEF STATEMENT OF NEED FOR ASSISTANCE. As applicable, explain effect of delay in receipt of Block 3 item(s) on achieving timely
shipment of Block 2 item(s) (e.g., production line shutdown), or the impact on program or project schedule. Describe attempts to resolve problems
and give specific reasons why assistance is required. If priority rating authority is requested, please state.

8. CERTIFICATION: I certify that the information contained in Blocks 1 - 7 of this form, and all other information attached, is correct and complete to
the best of my knowledge and belief.
_______________________________________________________________
Signature of Applicant's authorized official

______________________________________________________________
Title

_______________________________________________________________
Print or type name of authorized official

______________________________________________________________
Date

9.

U.S. GOVERNMENT AGENCY INFORMATION

a. Name/complete address of cognizant sponsoring service/agency/activity
headquarters office. Provide lower level activity, program, project, contract
administration, or field office information in Continuation Block below, on
duplicate of this page, or on separate sheet of paper.
Name _________________________________________________________
Address________________________________________________________

b. Case reference no. ____________________________________________

c. Government agency program or project to be supported by Block 2
item(s). Identify end-user agency if not sponsoring agency.

City______________________State ________________Zip______________
Contact name__ _________________________________________________
Signature __________________________________ Date ______________
Title___________________________________________________________
Telephone_ ________________________Fax__________________________
E-mail address: __________________________________________________
d. Statement of urgency of particular program or project and Applicant’s part in it. Specify the extent to which failure to obtain requested assistance will
adversely affect the program or project.

e. Government agency/activity actions taken to attempt resolution of problem.

f. RECOMMENDATION

g. ENDORSEMENT by authorized Department or Agency headquarters official.

_______________________________________________________________
Signature of authorized official

_______________________________________________________________
Type name of authorized official

_______________________________________________________________
Title

_______________________________________________________________
Date

CONTINUATION BLOCK
Identify each statement with appropriate block number

INSTRUCTIONS FOR SUBMITTING FORM BIS-999
REQUESTS FOR SPECIAL PRIORITIES ASSISTANCE (SPA) MAY BE SUBMITTED for any reason in support of the Defense Priorities and

Allocations System (DPAS) regulation; e.g.: when its regular provisions are not sufficient to obtain delivery of item(s)1 in time to meet urgent customer or program/
project requirements; for help in locating a supplier or placing a rated order; to ensure that rated orders are receiving necessary preferential treatment by suppliers; to
resolve production or delivery conflicts between or among rated orders; to verify the urgency or determine the validity of rated orders; or to request authority to use
a priority rating. Requests for SPA should be sponsored by the cognizant U.S. Government agency responsible for the program or project supported by the
Applicant's2 contract or purchase order, if applicable.

REQUESTS FOR SPA SHOULD BE TIMELY AND MUST ESTABLISH:

• The urgent need for the item(s); and that
• The Applicant has made a reasonable effort to resolve the problem.

APPLICANTS MUST COMPLETE BLOCKS 1-8.
SPONSORING U.S. GOVERNMENT AGENCY SHOULD COMPLETE BLOCK 9.
SPECIAL INSTRUCTIONS:

• If the space in any block is insufficient to provide a clear and complete statement of the information requested, use the Continuation Block provided on this form
or a separate sheet to be attached to this form.
• If SPA is requested for additional contracts or purchase orders placed with a supplier for the same or similar items, information from these contracts or purchase
orders may be included in one application. However, each contract or purchase order number must be identified and the quantities, priority rating, delivery
requirements, etc., must be shown separately.
• If disclosure of certain information on this form is prohibited by security regulations or other security considerations, enter "classified" in the appropriate block in
lieu of the restricted information.
• This form may be manually or electronically generated. Save the downloaded blank file to a computer and generate forms for submission via U.S. mail, email, or
fax. Navigate between the form’s data fields using the tab key, back tab, or backspace.

APPLICANTS REQUIRING PRIORITY RATING AUTHORIZATION TO OBTAIN PRODUCTION AND CONSTRUCTION
EQUIPMENT:

• For the performance of rated contracts or orders in support of Department of Defense (DOD) programs or projects, Applicants should submit DOD Form DD
691, "Application for Priority Rating for Production or Construction Equipment" in accordance with the instructions on that form to the DOD.
• For all other programs or projects, Applicants may use this form and submit to the appropriate Delegate Agency or the Department of Commerce.
• If the Delegate Agency is unable to resolve the problem or authorize the use of a priority rating, the Delegate Agency may forward the request to the Department
of Commerce for action.

WHERE TO SUBMIT THIS FORM:

• SPA requests should be sought from the Delegate Agency through the local contract administration officer, if applicable, or the Department of Commerce.
• To submit this form to the Department of Commerce, contact the Office of Strategic Industries and Economic Security, Room 3876, U.S. Department
of Commerce, Washington, D.C. 20230 (Attn.: DPAS); email DPAS@bis.doc.gov, telephone (202) 482-3634, or FAX (202) 482-5650.
• Foreign government or private sector entities should submit directly with the appropriate U.S. Government Agency per sections 700.56-58 of the DPAS
regulation.

CONTACTS FOR FURTHER INFORMATION:

• For any information related to the production or delivery of items against particular rated contracts or purchase orders, contact the local contract administration
officer of the Delegate Agency or the Department of Commerce.
• If the Delegate Agency for submitting this form cannot be determined, or for any other information or problems related to the completion and filing of this form,
the operation or administration of the DPAS, or to obtain a copy of the DPAS or any DPAS training materials, contact the Office of Strategic Industries and
Economic Security, Room 3876, U.S. Department of Commerce, Washington, D.C. 20230 (Attn.: DPAS); email DPAS@bis.doc.gov, telephone (202)
482-3634, or FAX (202) 482-5650.

FOOTNOTES:
1. "Item," as used in this form, refers to all materials, services, and facilities, including construction materials, the authority for which has not been delegated to
other agencies under Executive Order 13603 (also referred to as "Industrial Resources" as defined in the DPAS regulation).
2. "Applicant" as used in this form, refers to any Person requiring SPA, and eligible for such assistance under the DPAS. "Person" is defined in the DPAS
regulation to include any individual, corporation, partnership, association, or any other organized group of persons, or legal successor or representative thereof; or
any authorized State or local government agency thereof; and for purposes of the administration of this part, includes the United States Government and any
authorized foreign government or international organization or agency thereof, delegated authority as provided in the DPAS regulation.
BURDEN ESTIMATE AND REQUEST FOR COMMENT
Public reporting burden for this collection of information is estimated to average 30 minutes per response, including the time for reviewing instructions, gathering
the data needed, and completing the form. Please send comments regarding this burden estimate or any other aspect of this collection of information, including
suggestions for reducing the burden, to the Director of Administration, Bureau of Industry and Security, Room 6521, U.S. Department of Commerce,
Washington, D.C. 20230. Notwithstanding any other provision of law, no person is required to respond to, nor shall a person be subject to a penalty for failure to
comply with, a collection of information subject to the requirements of the Paperwork Reduction Act unless that collection of information displays a currently
valid OMB Control Number.