Form OST_F_1254 REQUEST FOR SPECIAL PRIORITIES ASSISTANCE

U.S. DEPARTMENT OF TRANSPORTATION
REQUEST FOR SPECIAL PRIORITIES ASSISTANCE
READ INSTRUCTIONS FOLLOWING FORM

FOR DOT USE
OMB Control Number: 2105-XXXX
Expiration Date: mm/dd/yyyy

You must submit a completed application in order to request Special Priorities Assistance (SPA). See sections 33.40-33.44 of the Transportation
Priorities and Allocations System (TPAS) regulation (49 CFR 33). 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 Transportation 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.
The U.S. Department of Transportation reserves the right to request more detailed information from Applicant(s) on any responses given in the
completed application for the purpose of making determinations for Special Priorities Assistance to Applicant(s).
PUBLIC BURDEN STATEMENT
A federal agency may not conduct or sponsor, and a person is not 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
current valid OMB Control Number. The OMB Control Number for this information collection is 2105-XXXX. Public reporting for this collection
of information is estimated to be approximately 30 minutes per response, including the time for reviewing instructions, gathering the data needed,
and completing and reviewing the collection of information. All responses to this collection of information are mandatory. Send comments
regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to: Defense
Production Act Activities Coordinator, U.S. Department of Transportation, Office of Intelligence, Security and Emergency Response, W56-306,
1200 New Jersey Avenue, SE, Washington, DC 20590.

1.

APPLICANT INFORMATION

a. Name and complete address of Applicant. Applicant can be any
person needing assistance – a government agency, a private company, a
contractor, or service supplier. See definition of "Applicant" in the
Instructions for this form.

b. If Applicant is not end-user, give name and complete address of the
end-user.

Applicant Name: ___________________________________________

Address: _________________________________________________

Address: __________________________________________________

City: ___________________________ State: _____ Zip: ___________

City: ___________________________ State: _____ Zip: ___________

Contact's name: _____________________________________________

Contact's name: _____________________________________________

Title: ____________________________________________________

Title: ____________________________________________________

Telephone: ______________________ Fax: ______________________

Telephone: ______________________ Fax: ______________________

E-mail address: ___________________________________________

E-mail address: ___________________________________________

Existing contract/purchase order #: ____________________________

Customer Name: ___________________________________________

Dated: ______________________ Priority Rating: _______________

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

Form OST F 1254
Page 1 of 6

OPI: Office of Intelligence, Security, and Emergency Response

U.S. DEPARTMENT OF TRANSPORTATION
REQUEST FOR SPECIAL PRIORITIES ASSISTANCE
READ INSTRUCTIONS FOLLOWING FORM

FOR DOT USE
OMB Control Number: 2105-XXXX
Expiration Date: mm/dd/yyyy

3. SERVICES OR ITEMS FOR WHICH APPLICANT REQUESTS ASSISTANCE
Name and Quantity

Description

Estimated Dollar Value

4. SUPPLIER OF ITEM OR SERVICE PROVIDER INFORMATION
a. Name and complete address of Applicant's Supplier/Provider.

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

Supplier/Provider Name: ____________________________________
Number: __________________________________________________
Address: __________________________________________________
Dated: ___________________________________________________
City: _____________________ State: _________ Zip: ______________
Contact Name: ______________________________________________

Priority rating:
(If none, so state)

Title: ______________________________________________________
Telephone: ___________________ Fax: __________________________
E-mail address: _____________________________________________

5. BRIEF JUSTIFICATION STATEMENT OF NEED FOR SPECIAL ASSISTANCE. Please provide a brief
justification for this request for Special Priorities Assistance. The justification should begin with the reason you are seeking Special Priorities
Assistance in support of the TPAS; e.g.: when its regular provisions are not sufficient to obtain delivery of service(s) or items(s) in time to meet urgent
customer or program requirements; or 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. If Applicant(s) are requesting authority to use a priority rating, please explain the
necessity of the requested items and/or services. As applicable, also explain the potential effects of delay in receipt of Section 3 items or services.
Describe attempts to procure items/services in normal market conditions and give specific reasons why special priority assistance is required. If DX
priority rating authority is requested, please explain the necessity over a DO priority rating.

Form OST F 1254
Page 2 of 6

OPI: Office of Intelligence, Security, and Emergency Response

U.S. DEPARTMENT OF TRANSPORTATION
REQUEST FOR SPECIAL PRIORITIES ASSISTANCE
READ INSTRUCTIONS FOLLOWING FORM

FOR DOT USE
OMB Control Number: 2105-XXXX
Expiration Date: mm/dd/yyyy

6. CERTIFICATION: I certify that the information contained in Sections 1 – 5 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 Applicant's authorized official

___________________________________________
Date

CONTINUATION SECTION
Identify each statement with appropriate Section number

Form OST F 1254
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OPI: Office of Intelligence, Security, and Emergency Response

Instructions for Using OMB Form 2105-XXXX
REQUEST FOR SPECIAL PRIORITIES ASSISTANCE
WHO DO I CONTACT FOR FURTHER
INFORMATION?
Email: [email protected]
Mail: Defense Production Act Activities
Coordinator,
U.S.
Department
of
Transportation, Office of Intelligence,
Security and Emergency Response, W56306, 1200 New Jersey Avenue, SE,
Washington, DC 20590
Phone: 202-366-1863
Fax: 202-366-4902
HOW DO I SUBMIT THIS FORM?
Email. Please fill out form electronically using
Adobe Acrobat Reader and send by email, if
possible. Otherwise, print and scan your signed
evaluation to a pdf document and email to
[email protected].
Fax. Fax your signed evaluation to (202) 3664902.You will receive an email confirmation.
DOT may contact you for additional clarifying
information, and will respond to you in a timely
manner with a decision regarding your request.
WHEN SHOULD THIS FORM BE USED?
Requests for Special Priorities Assistance (SPA)
may be filed with the U.S. Department of
Transportation (DOT) for any reason in support of
the Transportation Priorities and Allocations System
(TPAS); e.g.: when its regular provisions are not
sufficient to obtain delivery of service(s) or items(s)
in time to meet urgent customer or program
requirements; or help in locating a supplier or
placing a rated order; to ensure that rated orders are
receiving necessary preferential treatment by
Form OST F 1254
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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 U.S.
Government agency responsible for the program or
project supported by the Applicant's contract or
purchase order.
Generally, one form should be completed for each
contract or purchase order number. However, if
SPA is requested for multiple contracts or purchase
orders placed with a supplier for the same or similar
services or items, information from all contracts or
purchase orders may be included in one application.
However, each contract or purchase order number
must be identified and shown separately.
WHO SHOULD COMPLETE THE 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 DOT or the sponsoring U.S.
Government Agency, as applicable; prime
contractors file directly with DOT or the
sponsoring U.S. Government Agency, as applicable.
If for any reason the applicant is unable to file this
form as specified above, see section below on “Who
do I contact for further information?”
DEFINITIONS:
Applicant as used in this form refers to any person
requiring Special Priorities Assistance, and eligible
for such assistance under TPAS.
Item is defined in TPAS 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.
OPI: Office of Intelligence, Security, and Emergency Response

Person is defined in TPAS to include any
individual, corporation, partnership, association,
any other organized group of persons, a U.S.
Government agency, or any other government.

much, what is the description and also the
estimated dollar value of the item/service itself.
This helps DOT understand the scope of your
request.
Section 4:

Service is defined in TPAS to include any effort that
is needed for or incidental to (1) the development,
production, processing, distribution, deliver, or use of
an industrial resource or a critical technology item;
(2) the construction of facilities; (3) the movement of
individuals and property by all modes of civil
transportation; or (4) other national defense programs
and activities
SPECIFIC INSTRUCTIONS

This section helps DOT understand who your
supplier or service provider is. These are the people
who need to move faster to accomplish your
priority objective.
Section 5:
Please provide enough information so DOT
understands the need for and urgency of your
request.

Section 1:
Section 6:
a. Information about the applicant should go
here. An “applicant” refers to any person
requiring Special priorities Assistance and
eligible for such assistance under the TPAS.
A “person” in this context is any individual,
corporation, partnership, association, or
other organized group of persons, a US
Government agency or any other
government.
b. Information about the end-user or ultimate
customer for the item or service goes here.
Section 2:
Recognizing that many requests for special
priorities may involve interim services or items,
please complete this section describing the “end
product” that will be improved through providing
the priority listed. An example would be providing
freight rail transportation for a subcomponent of a
major item that is direly needed for the national
defense by the Government. Explain how the
transportation of the subcomponent will fulfill the
Government’s need.

This section certifies that the information is correct,
to the best knowledge of the person whose name
and/or signature is shown (depending on format of
form used). It is a criminal offense under 18 U.S.C.
1011 to make a willfully false statement or
representation to any U.S. Government agency as
to any matter within its jurisdiction.
Continuation Section
Understanding that situations requiring requests for
special priorities assistance may be complex and
information required not easily confined to sections
on a form, you are provided this opportunity to
provide any additional information that will assist
DOT in making a determination on your request.
SPECIAL INSTRUCTIONS:
•

•
Section 3:
Here you provide information on the item or
service you provide and seek special priority
assistance with. What is it called, how many or how
Form OST F 1254
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•

If the space in any block is insufficient to
provide a clear and complete statement of the
information requested, use a separate sheet to be
attached to this form.
If disclosure of certain information on this form
is prohibited by security regulations or other
security considerations, enter "classified" or
“confidential” in the appropriate block in lieu of
the restricted information.
The U.S. Department of Transportation

OPI: Office of Intelligence, Security, and Emergency Response

reserves the right to request more detailed
information from Applicant(s) on any
responses given in the completed application
for the purpose of making determinations for
Special Priorities Assistance to Applicant(s).

PRIVACY ACT STATEMENT
This notice is provided pursuant to the Privacy Act, 5, U.S.C. 552a(e)(3): The Information on this application is
solicited under the authority of Title 50 U.S.C. App. § 2061 et seq., the Defense Production Act of 1950. The
principal purpose for which the information is to be used is to determine your eligibility for Special Priorities
Assistance under the Transportation Priorities and Allocations System program. Contact information will be
used to notify you if Special Priorities Assistance has been granted, and to provide any other notifications
required by the program. Other possible uses of information are published in the Federal Register at 75 FR
82133 (December 29, 2010) under “Prefatory Statement of General Routine Uses”. Furnishing the information
on this form is voluntary, but failure to provide all or part of the information may delay or prevent the
processing of your application.

Form OST F 1254
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OPI: Office of Intelligence, Security, and Emergency Response