SR 383 (Rev 6-16-2015)
DOE-SR FOCI Submission
RFP / Contract Number Start Date End Date
Number _____ of Options for _____ years
Respondent’s (offeror or parent) Legal Identity Relationship of Respondent to Offeror
Respondent’s Principle Address
State of Incorporation and Full Date
Official Designated to Answer Questions Concerning this Information Telephone Number
Does your company (to include Tier Parents) have a current FOCI determination issued or presently
pending by any Department of Energy (DOE) / Department of Defense (DOD) field office?
Yes No
If
“No”,
the following documents must be returned as a part of this FOCI Submission package:
This cover sheet.
Statements of bidders/Offerors.
Certificate Pertaining to Foreign Interests (SF328).
Key Management Personnel Form (KMP) to include Facility Security Officer.
Representative of Foreign Interest Statement Form(s).
Publicly Traded Corporations: Annual Report, most recent SEC Forms 10K, and proxy statement.
Private Corporations: Current audited consolidated financial information.
Corporations: Attested copy of Corporate By-Laws to include all amendments.
Other
Other
NOTE: Several forms above are available via e-FOCI. Contact applicable FOCI Coordinator or Representative
If
“Yes”,
identify field office and date of prior FOCI Certificate Pertaining to Foreign Interests, facility code/cage code, sign and date below, and return
to SR procurement representative.
NOTE: A separate form is required for each tier parent.
Is your company (to include Tier Parents) currently under a FOCI Mitigation Plan?
Yes No
If
“Yes”,
identify the type of Mitigation Plan.
Type of Business Structure
Private Corporation
Public Corporation
Sole Proprietorship
Limited Partnership
General Partnership
Other
List Legal Identities of Parent Companies (all tiers) – if
more than one tier company exists, tier rankings must
be identified.
The offeror’s submission must include,
as a separate attachment,
a complete FOCI submission for each tier parent.
Rank Legal Name
Has your organization changed or used other names during the last 10 years? If
Yes
, attach a complete
listing of all name changes, and names used (including “DBA’s”), indicating applicable periods.
Yes No
Has your organization changed principle locations during the last 10 years? If
Yes
, attach a complete
listing of all principle address locations during the last 10 years, indicating applicable periods.
Yes No
I understand that the information provided is required to aid the DOE in identifying and mitigating factors of foreign ownership, control, and
influence over my company as prescribed by DOE Order 470.4B, Change 1, and DOE Order 472.2. I understand that failure to submit complete
and correct information and documentation responsive to the attached “Guidelines for Completing the FOCI Package / Certification” may prelude
contract eligibility
and
furthermore, that intentional omission or falsification of information relative to a FOCI submission constitutes a felony
criminal violation of 18 USC 1001 providing for penalties including fines up to $10,000 and /or imprisonment up to 5 years.
Official verifying submitted information as complete and correct:
Typed or Printed Name and Signature Title of Authorizing Official (KMP) Date Signed
click to sign
signature
click to edit
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