Form BIS-999 REQUEST FOR SPECIAL PRIORITIES ASSISTANCE

FORM BIS-999 (formerly form BXA-999)
REV. 4-03

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 __________________________

FILL OUT USING YOUR COMPUTER

Submission of a completed application is required to request Special Priorities Assistance (SPA). See sections 700.50-55 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. App. 2155(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. [Note: The Bureau of Export Administration is now
the Bureau of Industry and Security (BIS).]
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).

b. If Applicant is not end-user Government agency, give name and
complete address of Applicant's customer.
Customer Name _________________________________________________

Applicant Name _________________________________________________
Address________________________________________________________
Address________________________________________________________
City______________________State ________________Zip______________
City______________________State ________________Zip______________
Contact's name __________________________________________________
Contact's name_ _________________________________________________
Title ___________________________________________________________
Title___________________________________________________________
Telephone _______________________

FAX ________________________

Telephone_ ________________________Fax__________________________
Contract/purchase order no. ________________________________________
E-mail address: __________________________________________________
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

Description

Dollar Value

Pieces, units

Include identifying information such as model or part number

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________________________________________________________
Dated _________________________________________________________
City______________________State ________________Zip______________
Contact Name ___________________________________________________
Title ___________________________________________________________
Telephone_ ________________________Fax__________________________

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 so 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 (omit signature if this form is electronically generated and transmitted - use of name is deemed certification).
_______________________________________________________________
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 (omit signature if this form is electronically generated and transmitted –
use of name is deemed authorization). This endorsement is required for all Department of Defense and foreign government requests for assistance.
_______________________________________________________________
Signature of authorized official

_______________________________________________________________
Type name of authorized official

_______________________________________________________________
Title

_______________________________________________________________
Date

CONTINUATION BLOCK
Identify each statement with appropriate block number

INSTRUCTIONS FOR FILING FORM BIS-999
NOTE: You may fill out this form using your computer. Save the downloaded blank file to your computer and generate forms for submission via U.S.
mail, e-mail, or fax. Navigate between the form’s data fields using the tab key, back tab or backspace.
REQUESTS FOR SPECIAL PRIORITIES ASSISTANCE (SPA) MAY BE FILED for any reason in support of the Defense Priorities and Allocations System
(DPAS); 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 must be sponsored by the cognizant U.S. Government agency responsible for the program or project supported by the Applicant's2
contract or purchase order.
REQUESTS FOR SPA SHOULD BE TIMELY AND MUST ESTABLISH:
•
The urgent defense (including civil emergency) or energy program or project related need for the item(s); and that
•
The Applicant has made a reasonable effort to resolve the problem.
APPLICANT MUST COMPLETE BLOCKS 1-8. SPONSORING U.S. GOVERNMENT AGENCY/ACTIVITY MUST COMPLETE BLOCKS 9-10.
Sponsoring agency, if not the Department of Defense (DOD), must obtain DOD concurrence if the agency is supporting a DOD program or project. This form may
be mechanically or electronically prepared and may be mailed, FAXed, or electronically transmitted.
WHERE TO FILE THIS FORM:
•
Private sector Applicants should file with their respective customers as follows: lower-tier suppliers file with customer/subcontractor for forwarding to
subcontractor/prime contractor; subcontractors/suppliers file with prime contractor for forwarding to one of the below listed cognizant U.S. Government
(DPAS Delegate) agencies; prime contractors file directly with one of the below listed cognizant U.S. Government (DPAS Delegate) agencies:
- Department of Defense (DOD) -- File with the local Defense Contract Management Area Office, plant representative or contracting officer, or the appropriate
DOD military service, associated agency, program, or project office.
- Department of Energy (DOE) -- File with the appropriate Field Operations Office. Requests for SPA for domestic energy projects should be filed with
DOE headquarters in Washington, D.C.
- General Services Administration (GSA) and Federal Emergency Management Agency (FEMA) -- File with the contracting officer in the agency's
regional office or with its headquarters office in Washington, D.C.
•
Applicants who are lower level contract administration, program, project, or field offices, or when these activities cannot resolve the private sector
request for assistance, should forward this form to cognizant sponsoring service/agency/activity headquarters for review, Block 10 endorsement, and
forwarding to the U.S. Department of Commerce. Foreign government or private sector entities should file directly with the DOD Office of the
Secretary of Defense. Timely review and forwarding is essential to providing timely assistance.
•
If for any reason the Applicant is unable to file this form as specified above, see CONTACTS FOR FURTHER INFORMATION below.
CONTACTS FOR FURTHER INFORMATION:
•
For any information related to the production or delivery of items against particular rated contracts or purchase orders, contact the cognizant U.S.
Government agency, activity, contract administration, program, project, or field office (see WHERE TO FILE above).
•
If for any reason the Applicant is unable to file this form as specified in WHERE TO FILE above, if the cognizant U.S. Government agency for filing 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); telephone (202) 482-3634, or FAX (202) 482-5650.
APPLICANTS REQUIRING PRIORITY RATING AUTHORIZATION TO OBTAIN PRODUCTION OR CONSTRUCTION EQUIPMENT for the
performance of rated contracts or orders in support of DOD programs or projects must file DOD Form DD-691, "Application for Priority Rating for Production
or Construction Equipment" in accordance with the instructions on that form. For DOE, GSA, or FEMA programs or projects, Applicants may use this form
unless the agency requires its own form.
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.
•
Entries in Block 3 should be limited to information from a single contract or purchase order. 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.
FOOTNOTES:
1. "Item" is defined in the DPAS as any raw, in process or manufactured material, article, commodity, supply, equipment, component, accessory, part,
assembly, or product of any kind, technical information, process or service.
2. "Applicant" as used in this form, refers to any person requiring Special Priorities Assistance, and eligible for such assistance under the DPAS.
"Person" is defined in the DPAS to include any individual, corporation, partnership, association, any other organized group of persons, a U.S.
Government agency, or any other government.
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 3889, 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.