Standard Form 328 Certificate Pertaining to Foreign Interests

Form Approved
OMB No. 0704-0194
Expires Sep 30, 2007

CERTIFICATE PERTAINING TO FOREIGN INTERESTS
(Type or print all answers)

The public reporting burden for this collection of information is estimated to average 70 minutes 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 the burden, to the Department of Defense, Executive Services and Communications Directorate (0704-0194). Respondents should be aware
that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB
control number.

PLEASE DO NOT RETURN YOUR FORM TO THE ABOVE ORGANIZATION. RETURN COMPLETED FORM TO YOUR RESPECTIVE COGNIZANT SECURITY OFFICE.

PENALTY NOTICE
Failure to answer all questions or any misrepresentation (by omission
or concealment, or by misleading, false or partial answers) may serve
as a basis for denial of clearance for access to classified information.
In addition, Title 18, United States Code 1001, makes it a criminal
offense, punishable by a maximum of five (5) years imprisonment,
$15,000 fine or both, knowingly to make a false statement or repre-

sentation to any Department or Agency of the United States, as to
any matter within the jurisdiction of any Department or Agency of
the United States.

This includes any statement made herein

which is knowingly incorrect, incomplete or misleading in any
important particular.

PROVISIONS
1. This report is authorized by the Secretary of Defense, as Executive
Agent for the National Industrial Security Program, pursuant to
Executive Order 12829. While you are not required to respond, your
eligibility for a facility security clearance cannot be determined if you
do not complete this form. The retention of a facility security
clearance is contingent upon your compliance with the requirements
of DoD 5220.22-M for submission of a revised form as appropriate.

2. When this report is submitted in confidence and is so marked,
applicable exemptions to the Freedom of Information Act will be
invoked to withhold it from public disclosure.
3. Complete all questions on this form. Mark "Yes" or "No" for
each question. If your answer is "Yes" furnish in full the complete
information under "Remarks."

QUESTIONS AND ANSWERS
1. (Answer 1a. or 1b.)
a. (For entities which issue stock): Do any foreign person(s), directly or indirectly, own or have beneficial ownership
of 5 percent or more of the outstanding shares of any class of your organization's equity securities?

YES

b. (For entities which do not issue stock): Has any foreign person directly or indirectly subscribed 5 percent or more
of your organization's total capital commitment?
2. Does your organization directly, or indirectly through your subsidiaries and/or affiliates, own 10 percent or more of
any foreign interest?
3. Do any non-U.S. citizens serve as members of your organization's board of directors (or similar governing body),
officers, executive personnel, general partners, regents, trustees or senior management officials?
4. Does any foreign person(s) have the power, direct or indirect, to control the election, appointment, or tenure of
members of your organization's board of directors (or similar governing body) or other management positions of your
organization, or have the power to control or cause the direction of other decisions or activities of your organization?
5. Does your organization have any contracts, agreements, understandings, or arrangements with a foreign person(s)?
6. Does your organization, whether as borrower, surety, guarantor or otherwise have any indebtedness, liabilities or
obligations to a foreign person(s)?
7. During your last fiscal year, did your organization derive:
a. 5 percent or more of its total revenues or net income from any single foreign person?
b. In the aggregate 30 percent or more of its revenues or net income from foreign persons?
8. Is 10 percent or more of any class of your organization's voting securities held in "nominee" shares, in "street names"
or in some other method which does not identify the beneficial owner?
9. Do any of the members of your organization's board of directors (or similar governing body), officers, executive
personnel, general partners, regents, trustees or senior management officials hold any positions with, or serve as
consultants for, any foreign person(s)?
10. Is there any other factor(s) that indicates or demonstrates a capability on the part of foreign persons to control or
influence the operations or management of your organization?

STANDARD FORM 328 (Revised 7/2004)

PREVIOUS EDITION IS OBSOLETE.

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NO

REMARKS (Attach additional sheets, if necessary, for a full detailed statement.)

CERTIFICATION
I CERTIFY that the entries made by me above are true, complete, and correct to the best of my knowledge and belief and are made in
good faith.
WITNESSES:
(Date Certified)
By
(Signature of Authorized Contractor Representative)

(Typed Name of Contractor)
NOTE: In case of a corporation, a witness is not required but the
certificate below must be completed. Type or print names under
all signatures.

(Title of Authorized Contractor Representative)

(Address)
NOTE: Contractor, if a corporation, should cause the following certificate to be executed under its corporate seal, provided that the same
officer shall not execute both the Agreement and the Certificate.

CERTIFICATE
I,

, certify that I am the

of the corporation named as Contractor herein; that
who signed this certificate on behalf of the Contractor, was then
of said corporation; that said certificate was duly signed for and in behalf of said corporation by authority of its governing body, and is
within the scope of its corporate powers.

(Corporate Seal)

STANDARD FORM 328 (BACK) (Revised 7/2004)

(Signature and Date)

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