SF 328 Certificate Pertaining to Foreign Interests

OMB No. 0704-0194
OMB approval expires

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

PLEASE DO NOT RETURN YOUR FORM TO THE ORGANIZATION IN THE PARAGRAPH BELOW. RETURN COMPLETED FORM TO YOUR RESPECTIVE
COGNIZANT SECURITY OFFICE.

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, Washington Headquarters Services, Executive Services Directorate, Directives Division, Office of Information
Management, 4800 Mark Center Drive, East Tower, Suite 02G09, Alexandria, VA 22350-3100 (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.

PENALTY NOTICE
Failure to answer all questions or any misrepresentation (by omission or

or both, knowingly to make a false statement or representation to any

concealment, or by misleading, false or partial answers) may serve as a

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

basis for denial of clearance for access to classified information. In

the jurisdiction of any Department or Agency of the United States.

addition, Title 18, United States Code 1001, makes it a criminal offense,

This includes any statement made herein which is knowingly

punishable by a maximum of five (5) years imprisonment, $15,000 fine

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.

N E E D S

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."

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QUESTIONS AND ANSWERS

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YES

NO

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?
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 (20120501 DRAFT)

PREVIOUS EDITION IS OBSOLETE.

Adobe Professional 8.0

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

N E E D S

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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 and Date)

(Signature of Authorized Contractor Representative)

(Typed Name of Contractor)
NOTE: The witness must be a person who personally observed the
Contractor Representative sign this form. The witness cannot be
the same person who signs this form as the Government

(Title of Authorized Contractor Representative)

Representative. The name of the witness should be typed or printed
under the witness' signature and date.
(Address)
By executing this form, the Contractor Representative certifies that he or she is the
of the business entity identified above, and has the authority to bind the business entity to the terms of this agreement.

STANDARD FORM 328 (BACK) (20120501 DRAFT)

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