Form Standard Form 328 Standard Form 328 Certificate Pertaining to Foreign Interests

OMB No. 0704-0579
OMB approval
expires XXXXXXXX

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

RETURN THE CURRENT FORM AS DESCRIBED BELOW.
Return the form to your respective Cognizant Security Agency/Office granting the entity’s eligibility determination (e.g., facility security clearance) as referenced in 32 CFR Part 2004
under the National Industrial Security Program (NISP); to the Department of Homeland Security for the Classified Critical Infrastructure Protection Program (CCIPP); or, to the
Government Contracting Activity for the DoD Enhanced Security Program (DESP). The public reporting burden for this collection of information, 0704-0579, 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 the burden estimate or burden reduction suggestions to the Department of Defense, Washington Headquarters Services, at
[email protected]. 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 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 section 1001, makes it a criminal offense to knowingly make false statements or
representations 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 here in which is knowingly incorrect, incomplete, or misleading in any important particular.
PROVISIONS
1. The collection of this information is authorized by the Secretary of Defense, as Executive Agent for the NISP, pursuant to Executive Order 12829, further amended by
Section 6, of Executive Order 13691 to include the CCIPP. While you are not required to respond, your entity’s eligibility determination cannot be adjudicated if you do not
complete the form. The retention of an entity eligibility determination is contingent upon your compliance with the requirements of DoD 5220.22-M or equivalent for
submission of an accurate initial or revised form, as appropriate. This collection of information is also authorized by the Secretary of Defense for use in connection with the
DESP for the Department of Defense Innovation Initiative in accordance with subsection 951(c) of Public Law 114-328 (10 USC 1564 note). While you are not required to
respond, your eligibility to participate in the DESP cannot be determined if you do not complete this form accurately. Participation in the DESP is contingent, among other
things, upon your compliance with the requirements of the DESP for submission of an initial or revised form, as appropriate.
2. When this report is submitted in confidence and is so marked, applicable exemptions to the Freedom of Information Act (FOIA) will be invoked to withhold it from the
public disclosure if it is responsive to a FOIA request.
3. Complete all questions on this form. Mark “Yes” or “No” for each question. If your answer is “Yes” furnish complete supporting documentation, to include, but not limited
to, company or entity charter documents, board meeting minutes, stock or securities information, descriptions of organizational structures; contracts, sales, leases, and/or
loan agreements; and revenue documents, annual reports and income statements, etc.

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. Is 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?
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PREVIOUS EDITION IS OBSOLETE.

STANDARD FORM 328 (REV. 11/2018)

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:
WITNESS SIGNATURE

DATE CERTIFIED

SIGNATURE OF AUTHORIZED CONTRACTOR REPRESENTATIVE

DATE
By

NAME AND TITLE OF AUTHORIZED CONTRACTOR
REPRESENTATIVE

TYPED NAME OF WITNESS

NOTE: The witness must be a person who personally observed the
Contractor Representative sign this form. The witness cannot be the same
person who accepts this form as the Government representative. The name
of the witness should be typed or printed under the witness' signature and
date.

TYPED BUSINESS NAME OF CONTRACTOR

ADDRESS

By executing this form, the Contractor Representative certifies that he or she is the (title)
and has the authority to make the entries above on behalf of the business entity identified above.
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PREVIOUS EDITION IS OBSOLETE.

STANDARD FORM 328 (REV. 11/2018)