Exelis Systems Corporation
2013 ANNUAL SUPPLIER CERTIFICATION
SUPPLIER CODE:
EXELIS INC. USE ONLY
SUPPLIER NAME:
PARENT COMPANY NAME: (IF APPLICABLE)
STREET:
STREET:
CITY:
STATE/PROVINCE:
CITY:
STATE/PROVINCE:
ZIP/POSTAL:
COUNTRY:
ZIP/POSTAL:
COUNTRY:
PHONE:
EMPLOYEE TOTAL:
PHONE:
EMPLOYEE TOTAL:
FAX:
CAGE/FSCM:
PARENT WEBSITE:
WEBSITE:
BILLING INFORMATION (IF DIFFERENT FROM SUPPLIER ADDRESS):
NAICS U.S. INDUSTRY #:
STREET:
TAX ID #:
CITY:
STATE/PROVINCE:
DUNS #:
ZIP/POSTAL:
COUNTRY:
The procurement of material supplies or services for a U.S. Government contract requires compliance by Prime Contractors,
Subcontractors, and Suppliers with various programs enacted into law, implemented by Executive Order and declared by
Federal Regulations.
THE FOLLOWING CERTIFICATIONS ARE EFFECTIVE FOR A PERIOD OF 12 MONTHS BEGINNING ON THE DATE OF SIGNATURE OF THIS DOCUMENT. IF THERE
IS ANY CHANGE TO YOUR STATUS UNDER ANY OF THE FOLLOWING CERTIFICATIONS DURING THE PERIOD, YOU ARE REQUIRED TO INFORM THE EXELIS
INC. BUSINESS UNIT NAMED ON THE ACCOMPANYING LETTERHEAD IN WRITING PROMPTLY, NO LATER THAN FIFTEEN (15) DAYS FROM THE CHANGE IN
STATUS.
U.S. OWNED ENTITIES:
SECTION I AND VI ARE REQUIRED BY EXELIS INC. TRADE COMPLIANCE. SECTIONS III & IV ARE REQUIRED BY EXELIS INC. TO UPDATE SUPPLIER
RECORDS. SECTION V CONTAINS CERTIFICATIONS WHICH REQUIRE YOUR ACKNOWLEDGMENT PRIOR TO ANY SOLICITATION OR PURCHASE ORDER
ACTIVITY. PLEASE REVIEW AND COMPLETE SECTIONS: I, III, IV, V, VI AND SIGN. THERE ARE NO EXCEPTIONS FOR ANY REQUIRED
SECTION.
NON-U.S. OWNED/ FOREIGN CONTROLLED ENTITIES:
SECTION II AND VI ARE REQUIRED BY EXELIS INC. TRADE COMPLIANCE. SECTIONS III & IV ARE REQUIRED BY EXELIS INC. TO UPDATE SUPPLIER
RECORDS. SECTION V CONTAINS CERTIFICATIONS WHICH REQUIRE YOUR ACKNOWLEDGEMENT PRIOR TO ANY SOLICITATION OR PURCHASE ORDER
ACTIVITY. PLEASE REVIEW AND COMPLETE SECTIONS: II, III, IV, V, VI AND SIGN. THERE ARE NO EXCEPTIONS FOR ANY REQUIRED
SECTION.
Form PU-125 (Rev. 01/13)
Previous editions are obsolete
[Source: XLS 9438 (Version date 12/12)
Use/disclosure of data on this sheet is subject to the restrictions as stated
in this form’s directive, the SBSP, and the Corporate Purchasing Manual.
Page 1 of 14
SECTION I: EXPORT COMPLIANCE CERTIFICATION (DOMESTIC)
THIS SECTION TO BE COMPLETED BY U.S. OWNED ENTITIES ONLY
EXELIS INC. REQUIRES THAT ITS SUPPLIERS CERTIFY CERTAIN INFORMATION NECESSARY TO ENSURE COMPLIANCE WITH U.S. GOVERNMENT EXPORT
CONTROL LAWS AND REGULATIONS. ADHERENCE TO THIS REQUIREMENT IS NECESSARY BEFORE EXELIS INC. WILL PLACE, OR CONTINUE TO PLACE, ANY
ORDERS, PARTICIPATE IN TECHNICAL DISCUSSIONS OR PROVIDE ANY ITEMS, DATA, OR ASSISTANCE. THIS CERTIFICATION MUST BE SIGNED BY A DULY
AUTHORIZED OFFICER OF YOUR COMPANY.
A. SUPPLIER EXPORT COMPLIANCE POINT OF CONTACT
THE PERSON BELOW IS AUTHORIZED TO DISCUSS/VERIFY/CONFIRM THE EXPORT COMPLIANCE REQUIREMENTS ASSOCIATED WITH THIS
CERTIFICATION.
COMPANY NAME:
POINT OF CONTACT:
TITLE:
PHONE:
FAX:
EMAIL ADDRESS:
B. U.S. REGISTRATION REQUIREMENTS (22 CRF § 122.1)
ALL EXELIS INC. SUPPLIERS MUST COMPLY WITH THE U.S. REGULATORY REQUIREMENTS CONTAINED IN THE U.S. INTERNATIONAL TRAFFIC IN
ARMS REGULATIONS (ITAR); 22 CRF §122.1:
(A) ANY PERSON WHO ENGAGES IN THE UNITED STATES IN THE BUSINESS OF EITHER MANUFACTURING OR EXPORTING DEFENSE ARTICLES OR
FURNISHING DEFENSE SERVICES IS REQUIRED TO REGISTER WITH THE DIRECTORATE OF DEFENSE TRADE CONTROLS. MANUFACTURERS OF
DEFENSE ARTICLES WHO DO NOT ENGAGE IN EXPORTING MUST NEVERTHELESS REGISTER.
IS YOUR COMPANY REGISTERED WITH THE DIRECTORATE OF DEFENSE TRADE CONTROLS, U.S. DEPARTMENT OF STATE?
YES
EXPIRATION DATE: _
_________ (MM/DD/YY) -
CONTINUE TO D AND E.
(If expiring within current calendar year, please remember to start Renewal Activities)
NEW APPLICATION IN PROCESS
APPLICATION DATE: __
________ (MM/DD/YY) -
CONTINUE TO D AND E.
RENEWAL APPLICATION IN PROCESS APPLICATION DATE: __
________ (MM/DD/YY) -
CONTINUE TO D AND E.
NO
C.
IF “NO”, PLEASE COMPLETE C BELOW BEFORE CONTINUING TO D AND E.
OUR BUSINESS IS NOT REQUIRED TO BE REGISTERED WITH THE U.S. DEPARTMENT OF STATE FOR THE FOLLOWING REASON:
CHECK ONLY ONE BOX.
WE SUPPLY/MANUFACTURE PRODUCTS THAT ARE SUBJECT EXCLUSIVELY TO THE CONTROLS OF THE EXPORT ADMINISTRATION
REGULATION (EAR) AND THEY ARE CLASSIFIED AS _
__________________________ (PROVIDE THE EXPORT CONTROL
CLASSIFICATION NUMBER/ECCN).
OUR PERTINENT BUSINESS ACTIVITY IS CONFINED EXCLUSIVELY TO THE PRODUCTION OF UNCLASSIFIED TECHNICAL DATA ONLY.
THEREFORE, 22 CFR § 122.1(B)(2) APPLIES. NOTE: ONLY ONE OCCASION OF MANUFACTURING A DEFENSE ARTICLE IS NEEDED TO
EFFECT THE MANUFACTURER REGISTRATION REQUIREMENT.
OUR BUSINESS ENGAGES ONLY IN THE FABRICATION OF ARTICLES FOR EXPERIMENTAL OR SCIENTIFIC PURPOSE, INCLUDING RESEARCH
AND DEVELOPMENT. THEREFORE, 22 CFR § 122.1(B)(4) APPLIES.
OUR ACTIVITIES AS A DISTRIBUTOR/RESELLER HAVE NOT AND DO NOT INVOLVE THE MANUFACTURE OR EXPORT OF DEFENSE ARTICLES.
Form PU-125 (Rev. 01/13)
Previous editions are obsolete
[Source: XLS 9438 (Version date 12/12)
Use/disclosure of data on this sheet is subject to the restrictions as stated
in this form’s directive, the SBSP, and the Corporate Purchasing Manual.
Page 2 of 14
OUR SERVICE ACTIVITIES INVOLVING DEFENSE ARTICLES DO NOT INCLUDE BRAZING, BORING OUT HOUSINGS, OR ASSEMBLY. (THESE
SERVICES DO CONSTITUTE THE MANUFACTURE OF DEFENSE ARTICLES AND DO REQUIRE MANUFACTURER REGISTRATION.)
WE ARE A CONSULTANT TO EXELIS INC., PROVIDING OTHER BUSINESS SERVICES. NONE OF THE AFOREMENTIONED OPTIONS APPLY TO
OUR SERVICE AGREEMENT WITH EXELIS INC.
OTHER (PLEASE EXPLAIN): _
__________________________
D. INTERNATIONAL TRAFFIC IN ARMS REGULATIONS 22 CFR §120-130
1.
ARE YOU A U.S. COMPANY OR OTHER U.S. LEGAL ENTITY?
YES
NO
2.
DOES YOUR COMPANY EMPLOY NON-U.S. PERSONS OR USE NON-U.S. PERSONS AS CONTRACT LABOR OR CONSULTANTS AT ANY OF ITS
U.S. LOCATIONS?
YES
NO
3.
DOES YOUR COMPANY PERFORM WORK AT NON-U.S. FACILITIES, AFFILIATES OR SUBSIDIARIES?
YES
NO
4.
WILL ANY THIRD PARTY WHO IS A NON-U.S. COMPANY OR WHO WILL UTILIZE NON-U.S. FACILITIES OR NON-U.S. PERSONS BE
INVOLVED IN ANY WAY ON ANY EXELIS INC. TRANSACTIONS?
YES
NO
5.
SUPPLIER HAS DEVELOPED AND DEPLOYED PROCESSES SUFFICIENT TO MEET THE REQUIREMENTS OF 22 CFR PARTS 120 -130,
FURTHER DEFINED AT HTTP://WWW.PMDDTC.STATE.GOV/REGULATIONS_LAWS/ITAR.HTML
YES
NO
E. EXPORT COMPLIANCE REQUIREMENT, PLEASE READ THE FOLLOWING AND SIGN THE CERTIFICATION BELOW:
SUPPLIER HEREBY ACKNOWLEDGES THAT CERTAIN GOODS, DATA AND/OR SERVICES TO BE PROVIDED BY EXELIS INC. UNDER A CONTRACT OR
PURCHASE ORDER ARE SUBJECT TO U.S. GOVERNMENT EXPORT CONTROL REGULATIONS INCLUDING THE INTERNATIONAL TRAFFIC IN ARMS
REGULATIONS (ITAR) AND THE EXPORT ADMINISTRATION REGULATIONS (EAR). ANY DOCUMENTATION PROVIDED TO SUPPLIER WHICH IS
DEFINED AS TECHNICAL DATA (INFORMATION REGARDING THE DESIGN, DEVELOPMENT, MANUFACTURE, PRODUCTION, ASSEMBLY,
TESTING, REPAIR, MAINTENANCE OR MODIFICATION OF EXELIS INC. PRODUCTS OR SERVICES, HEREINAFTER CALLED “BUYER’S TECHNICAL
DATA”) IS SUBJECT TO U.S. GOVERNMENT EXPORT CONTROL REGULATIONS (EXPORT ADMINISTRATION REGULATIONS, “EAR” OR
INTERNATIONAL TRAFFIC IN ARMS REGULATIONS, “ITAR”), AND SUPPLIER MAY NOT DISCLOSE BUYER’S TECHNICAL DATA TO ANY FOREIGN
NATIONAL OR FOREIGN COUNTRY WITHOUT PRIOR WRITTEN APPROVAL FROM EXELIS INC. AND EITHER FROM THE U.S. DEPARTMENT OF
COMMERCE (EAR) OR THE U.S. DEPARTMENT OF STATE (ITAR). I UNDERSTAND THAT I AM OBLIGATED TO REVIEW ALL INFORMATION
PROVIDED AND IN THE EVENT OF ANY AMBIGUITY, CONTACT EXELIS INC. IMMEDIATELY TO OBTAIN ANY EXPORT CONTROL DETERMINATION
IN CASES WHERE EXPORT CONTROL JURISDICTION HAS NOT BEEN CLEARLY MARKED OR OTHERWISE IDENTIFIED BY EXELIS INC.
SUPPLIER HEREBY ACKNOWLEDGES NOTIFICATION OF THE REQUIREMENT TO DISCLOSE TO EXELIS INC. ANY EMPLOYEES, BY COUNTRY, WHO
HOLD DUAL-CITIZENSHIP STATUS.
SUPPLIER CERTIFIES THAT ALL EMPLOYEES OR REPRESENTATIVES OF OUR COMPANY THAT WILL INTERACT WITH EXELIS INC. ARE NOT
DEBARRED OR OTHERWISE RESTRICTED FROM PARTICIPATION IN GOVERNMENT CONTRACTING OR INTERNATIONAL TRANSACTIONS
CONDUCTED UNDER THE JURISDICTION OF THE EAR AND ITAR.
I CERTIFY THAT TO THE BEST OF MY KNOWLEDGE THE ABOVE INFORMATION IS TRUE AND CORRECT AND THAT OUR COMPANY SHALL BE
RESPONSIBLE FOR ENSURING THAT THE REQUIREMENTS OF THIS CERTIFICATION ARE CONVEYED TO ALL SUB-TIER SUPPLIER THAT RECEIVE
TECHNICAL DATA, EQUIPMENT OR TECHNOLOGY OF EXELIS INC.
______________________________________
PRINTED NAME & TITLE
______________________________
COMPANY NAME
________________________________________
SIGNATURE
_______________________________
DATE
Form PU-125 (Rev. 01/13)
Previous editions are obsolete
[Source: XLS 9438 (Version date 12/12)
Use/disclosure of data on this sheet is subject to the restrictions as stated
in this form’s directive, the SBSP, and the Corporate Purchasing Manual.
Page 3 of 14
SECTION II: EXPORT COMPLIANCE CERTIFICATION (FOREIGN OWNED/FOREIGN CONTROLLED)
THIS SECTION TO BE COMPLETED BY FOREIGN OWNED/FOREIGN CONTROLLED ENTITIES ONLY
A. NON-U.S./FOREIGN SUPPLIER EXPORT COMPLIANCE POINT OF CONTACT
THE PERSON BELOW IS AUTHORIZED TO DISCUSS/VERIFY/CONFIRM THE EXPORT COMPLIANCE REQUIREMENTS ASSOCIATED WITH THIS
CERTIFICATION.
COMPANY NAME:
POINT OF CONTACT:
TITLE:
PHONE:
FAX:
EMAIL ADDRESS:
B. CONTROL AND DISCLOSURE
1.
SUPPLIER HEREBY ACKNOWLEDGES NOTIFICATION THAT ANY DOCUMENTATION PROVIDED TO SUPPLIER WHICH IS DEFINED AS TECHNICAL
DATA (INFORMATION REGARDING THE DESIGN, DEVELOPMENT, MANUFACTURE, PRODUCTION, ASSEMBLY, TESTING, REPAIR,
MAINTENANCE OR MODIFICATION OF EXELIS INC. PRODUCTS OR SERVICES, HEREINAFTER CALLED “BUYER’S TECHNICAL DATA”) IS SUBJECT
TO U.S. GOVERNMENT EXPORT CONTROL REGULATIONS (EXPORT ADMINISTRATION REGULATIONS, “EAR” OR INTERNATIONAL TRAFFIC IN
ARMS REGULATIONS, “ITAR”), AND SUPPLIER MAY NOT DISCLOSE BUYER’S TECHNICAL DATA TO ANY FOREIGN NATIONAL OR FOREIGN
COUNTRY WITHOUT PRIOR WRITTEN APPROVAL FROM EXELIS INC. AND EITHER FROM THE U.S. DEPARTMENT OF COMMERCE (EAR) OR THE
U.S. DEPARTMENT OF STATE (ITAR).
2.
SUPPLIER HEREBY ACKNOWLEDGES NOTIFICATION OF THE REQUIREMENT TO DISCLOSE TO EXELIS INC. ANY EMPLOYEES, BY COUNTRY, WHO
HOLD DUAL-CITIZENSHIP STATUS WITH A COUNTRY OTHER THAN THE U.S. (E.G., THEY ARE CITIZENS OF YOUR COUNTRY AND A THIRD
COUNTRY, OTHER THAN THE U.S.).
C. LABOR SERVICES
1.
YES
NO
DOES YOUR COMPANY EMPLOY HOST COUNTRY/LOCAL NATIONALS (HCN), THIRD COUNTRY
NATIONALS (TCN) OR DUAL NATIONALS (DCN) AS CONTRACT LABOR OR CONSULTANTS? IF YES, PLEASE PROVIDE US A LIST
INDICATING THE CITIZENSHIP AND COUNTRY OF BIRTH (AS LISTED ON PASSPORT) OF YOUR EMPLOYEES AND ATTACH IT TO THIS
CERTIFICATION.
2.
YES
NO
DOES YOUR COMPANY EMPLOY ANY HOST COUNTRY/LOCAL NATIONALS (HCN), THIRD
COUNTRY NATIONALS, (TCN) OR DUAL NATIONALS (DN) WHO HAVE PASSPORTS OR WERE BORN IN THE FOLLOWING
COUNTRIES? (AFGHANISTAN, BURMA, BELARUS, CHINA, COTE D’LVOIRE, CUBA, CYPRUS, DEMOCRATIC REPUBLIC OF THE CONGO,
ERITREA, HAITI, IRAN, IRAQ, LEBANON, LIBERIA, LIBYA, NORTH KOREA, RWANDA, RUSSIA, SIERRA LEONE, SOMALIA, SUDAN,
SYRIA, VENEZUELA, VIETNAM, YEMEN, ZIMBABWE AND SHRI LANKA) IF YES, PLEASE CIRCLE THOSE THAT APPLY
3.
YES
NO
WILL YOU BE PROVIDING EXELIS SYSTEMS CORPORATION ANY HOST NATIONALS (HCN), THIRD
COUNTRY NATIONALS (TCN), OR DUAL NATIONALS (DCN) THAT WILL BE WORKING ON DEFENSE ARTICLES? (SEE DEFINITIONS
ON PAGE 2) IF YES, YOU WILL NEED A SIGNED TECHNICAL ASSISTANCE AGREEMENT (TAA) APPROVED BY THE UNITED STATES
STATE DEPARTMENT. EXELIS SYSTEMS CORPORATION WILL APPLY FOR THE TAA.
4.
YES
NO
DOES YOUR COMPANY EMPLOY AND PROVIDE ANY LABOR PROVIDERS TO EXELIS SYSTEMS CORPORATION
CORPORATION THAT IS A U.S. PERSON? A U.S. PERSON IS SOMEONE WHO IS A U.S. CITIZEN OR U.S. PERMANENT RESIDENT
ALIEN (SOMETIMES REFERRED TO AS A “GREEN CARD HOLDER”).
5.
YES
NO
WILL YOU SUBCONTRACT ANY OF YOUR LABOR SERVICES OUT TO NON-U.S. COMPANIES IN ANY
WAY?
Form PU-125 (Rev. 01/13)
Previous editions are obsolete
[Source: XLS 9438 (Version date 12/12)
Use/disclosure of data on this sheet is subject to the restrictions as stated
in this form’s directive, the SBSP, and the Corporate Purchasing Manual.
Page 4 of 14
D. CERTIFICATION
I CERTIFY THAT TO THE BEST OF MY KNOWLEDGE THE ABOVE INFORMATION IS TRUE AND CORRECT AND THAT OUR COMPANY SHALL BE
RESPONSIBLE FOR ENSURING THAT THE REQUIREMENTS OF THIS CERTIFICATION ARE CONVEYED TO ALL SUB-TIER SUPPLIER THAT RECEIVE
BUYER’S TECHNICAL DATA, EQUIPMENT OR TECHNOLOGY. I further certify that all employees or representatives of our
company that will represent our company to or interact with Exelis Inc. are not debarred or otherwise restricted from
participation in government contracting or international transactions conducted under the jurisdiction of the EAR
and ITAR.
PRINTED NAME & TITLE
COMPANY NAME
SIGNATURE
DATE
Form PU-125 (Rev. 01/13)
Previous editions are obsolete
[Source: XLS 9438 (Version date 12/12)
Use/disclosure of data on this sheet is subject to the restrictions as stated
in this form’s directive, the SBSP, and the Corporate Purchasing Manual.
Page 5 of 14
SECTION III: BUSINESS INFORMATION
THIS SECTION TO BE COMPLETED BY ALL SUPPLIERS
A. THE SUPPLIER, BY CHECKING THE APPLICABLE BOX, REPRESENTS THAT:
a.
OWNERSHIP OF THE ENTITY IS:
U.S.-OWNED
U.S. INCORPORATED WITH FOREIGN PARENT
FOREIGN-OWNED, REGISTERED FOR BUSINESS IN _
b.
__ (COUNTRY).
IT OPERATES AS
A CORPORATION INCORPORATED UNDER THE LAWS OF _
___ (STATE).
SOLE PROPRIETORSHIP
PARTNERSHIP
NON-PROFIT ORGANIZATION
B. COMMON PARENT
COMMON PARENT MEANS THAT A CORPORATE ENTITY WHICH OWNS OR CONTROLS AN AFFILIATED GROUP OF CORPORATIONS THAT FILES ITS
FEDERAL TAX RETURNS ON A CONSOLIDATED BASIS, ONE OF WHICH THE SUPPLIER IS A MEMBER.
SUPPLIER IS NEITHER OWNED NOR CONTROLLED BY A COMMON PARENT.
SUPPLIER IS OWNED OR CONTROLLED BY A COMMON PARENT.
COMMON PARENT NAME:
C.
_______________
CHECK ALL APPLICABLE BOX(ES) AS DESCRIBED UNDER FAR 19.001 DEFINITIONS AND FAR 19.201 GENERAL POLICY:
LARGE BUSINESS
SMALL BUSINESS
FOREIGN BUSINESS
UNDER 15 U.S.C./645(D), ANY PERSON WHO MISREPRESENTS A FIRM’S STATUS IN ORDER TO OBTAIN A CONTRACT TO BE AWARDED THE
BELOW PREFERENCE PROGRAMS ESTABLISHED PURSUANT TO SECTION 8(A), 8 (D) OR 9 OR 15 OF THE SMALL BUSINESS ACT OR ANY OTHER
PROVISION OF FEDERAL LAW THAT SPECIFICALLY REFERENCES 8(D) FOR A DEFINITION OF PROGRAM ELIGIBILITY SHALL:
1. BE PUNISHED BY IMPOSITION OF FINE, IMPRISONMENT OR BOTH:
2. BE SUBJECT TO ADMINISTRATIVE REMEDIES, INCLUDING SUSPENSION AND DEBARMENT; AND
3. BE INELIGIBLE FOR PARTICIPATION IN PROGRAMS CONDUCTED UNDER THE AUTHORITY OF THE ACT.
IF SMALL, CHECK ALL APPLICABLE BOXES
SMALL DISADVANTAGED BUSINESS (SDB) CONCERN
WOMAN-OWNED SMALL BUSINESS (WOSB) CONCERN
HISTORICALLY BLACK COLLEGE/UNIVERSITY (HBCU) OR MINORITY INSTITUTION (MI)
HUBZONE SMALL BUSINESS (HUBZONE SB) CONCERN*
VETERAN-OWNED SMALL BUSINESS (VOSB) CONCERN
SERVICE-DISABLED VETERAN-OWNED SMALL BUSINESS (SDVOSB) CONCERN
ALASKA NATIVE CORPORATION (ANC) OR INDIAN TRIBE
ANC, NOT CERTIFIED BY SMALL BUSINESS ADMINISTRATION AS SMALL DISADVANTAGED BUSINESS (SDB)
ANC, NOT A SMALL BUSINESS
*IF YOUR COMPANY HAS IDENTIFIED ITSELF AS A HUBZONE SMALL BUSINESS CONCERN, YOU MUST PROVIDE A COPY OF CERTIFICATION
FROM THE U.S. SMALL BUSINESS ADMINISTRATION.
Form PU-125 (Rev. 01/13)
Previous editions are obsolete
[Source: XLS 9438 (Version date 12/12)
Use/disclosure of data on this sheet is subject to the restrictions as stated
in this form’s directive, the SBSP, and the Corporate Purchasing Manual.
Page 6 of 14
D. DID YOUR BUSINESS OR ORGANIZATION (REPRESENTED BY A DUNS NUMBER) DURING YOUR PRECEDING COMPLETED FISCAL YEAR REALIZE
80% OR MORE OF ITS ANNUAL GROSS REVENUES FROM U.S. FEDERAL CONTRACTS, SUBCONTRACTS, LOANS, GRANTS, SUB-GRANTS AND
COOPERATIVE AGREEMENTS?
YES
E.
NO
DID YOUR BUSINESS OR ORGANIZATION (REPRESENTED BY A DUNS NUMBER) DURING YOUR PRECEDING COMPLETED FISCAL YEAR REALIZE
$25,000,000 OR MORE OF ITS ANNUAL GROSS REVENUES FROM U.S. FEDERAL CONTRACTS, SUBCONTRACTS, LOANS, GRANTS, SUBGRANTS,
AND COOPERATIVE AGREEMENTS?
YES
F.
NO
DOES THE PUBLIC HAVE ACCESS TO INFORMATION ABOUT THE COMPENSATION OF THE EXECUTIVES IN YOUR BUSINESS OR ORGANIZATION
(REPRESENTED BY A DUNS NUMBER) THROUGH PERIODIC REPORTS FILED UNDER SECTION 13(A) OF THE SECURITIES EXCHANGE ACT OF 1934
(15 U.S.C. 78M(A), 78O(D)) OR SECTION 6104 OF THE INTERNAL REVENUE CODE OF 1986?
YES
NO
IF THE ANSWERS TO BOTH D & E. ABOVE WERE “YES” AND THE ANSWER TO F WAS “NO”, THEN REPORT THE NAME AND TOTAL COMPENSATION OF
THE FIVE MOST HIGHLY COMPENSATED EXECUTIVES FOR THE SUPPLIER’S PRECEDING FISCAL YEAR BELOW.
EXECUTIVE NAME
TOTAL COMPENSATION IN U.S. DOLLARS
1.
2.
3.
4.
5.
NOTE - FAR 52.204-10 AND THE FEDERAL FUNDING ACCOUNTABILITY AND TRANSPARENCY ACT OF 2006 (PUB. LAW 109-282), AMENDED BY THE
GOVERNMENT FUNDING TRANSPARENCY ACT OF 2008 (PUB. LAW 110-252), REQUIRES EXELIS INC. TO REPORT INFORMATION ON SUBCONTRACT
AWARDS. THIS LAW REQUIRES ALL REPORTED INFORMATION TO BE MADE PUBLIC.
G. .DOES ANY ITEM, COMPONENT, OR PRODUCT YOU SUPPLY TO EXELIS INC. CONTAIN CONFLICT MINERALS (TIN, TANTALUM, TUNGSTEN OR
GOLD) AND ARE THOSE MINERAL NECESSARY FOR THE FUNCTIONALITY AS DESCRIBED IN SECTION 1502 OF THE DODD-FRANK ACT?
YES
NO
N/A SERVICE PROVIDER ONLY
IF YES, DO ANY OF THE MINERALS ORIGINATE FROM THE DEMOCRATIC REPUBLIC OF THE CONGO (DRC) OR ADJOINING COUNTRY?
YES
NO
UNDETERMINABLE
IF YES, OR UNDETERMINABLE, PLEASE LIST THOSE SPECIFIC ITEMS, COMPONENTS, OR PRODUCTS:
______________________________________________________________________________
H. WE UNDERSTAND THAT OUR COMPANY IS OBLIGATED TO PROVIDE INFORMATION ON CERTAIN PAYMENTS IN ACCORDANCE WITH 22 CFR
130. SPECIFICALLY, IF OUR COMPANY PROVIDES OVER $500,000 OF SUPPLIES TO EXELIS INC, OUR COMPANY WILL PROVIDE EXELIS INC.
INFORMATION ON ALL PAYMENTS OF FEES COMMISSIONS AND POLITICAL CONTRIBUTIONS PAID BY OUR COMPANY WITH RESPECT TO THE
SALE TO EXELIS INC.
OUR COMPANY SHALL ALSO SUPPLY INFORMATION OF FEES, COMMISSIONS AND POLITICAL CONTRIBUTIONS MADE BY
OUR SUPPLIERS.
YES
Form PU-125 (Rev. 01/13)
Previous editions are obsolete
[Source: XLS 9438 (Version date 12/12)
NO
Use/disclosure of data on this sheet is subject to the restrictions as stated
in this form’s directive, the SBSP, and the Corporate Purchasing Manual.
Page 7 of 14
SECTION IV: BUSINESS RESPONSIBILITIES & RESPONSIVENESS
THIS SECTION TO BE COMPLETED BY ALL SUPPLIERS
A. BUSINESS CONTINUITY PLAN
CHECK ONLY ONE BOX.
SUPPLIER HAS A CONTINUITY PLAN IN PLACE. SUPPLIER WILL (A) PROMPTLY NOTIFY EXELIS INC. IN THE EVENT OF A FORCE MAJUERE EVENT,
(B) MAINTAIN PARTIAL PERFORMANCE AS REASONABLY POSSIBLE, AND (C) RESUME FULL PERFORMANCE AS SOON AS IS REASONABLY POSSIBLE.
SUPPLIER DOES NOT HAVE A CONTINUITY PLAN IN PLACE. SUPPLIER WILL (A) PROMPTLY NOTIFY EXELIS INC. IN THE EVENT OF A FORCE
MAJUERE EVENT, (B) MAINTAIN PARTIAL PERFORMANCE AS REASONABLY POSSIBLE, AND (C) RESUME FULL PERFORMANCE AS SOON AS IS
REASONABLY POSSIBLE.
B. COUNTERFEIT PARTS PREVENTION PROGRAM
CHECK ONLY ONE BOX.
SUPPLIER HAS A COUNTERFEIT PARTS PREVENTION PROGRAM IN PLACE MEETING THE REQUIREMENTS OF SECTION 818 OF THE NATIONAL
DEFENSE AUTHORIZATION ACT FOR FISCAL YEAR 2012.
SUPPLIER DOES NOT HAVE A COUNTERFEIT PARTS PREVENTION PROGRAM IN PLACE.
PLEASE PROVIDE REASON(S) AND/OR PLAN AND SCHEDULE FOR COMPLIANCE: _
_
C. SUPPLIER BUSINESS SYSTEMS
CHECK ONLY ONE BOX
SUPPLIERS INTERNAL BUSINESS SYSTEMS COMPLY WITH THE TERMS AND CONDITIONS OF THE BUSINESS SYSTEMS CLAUSE IN DFARS 252.2427005, INCLUDING AS APPLICABLE – ACCOUNTING SYSTEM, ESTIMATING SYSTEM, PURCHASING SYSTEM, EARNED VALUE MANAGEMENT SYSTEM,
MATERIAL MANAGEMENT AND ACCOUNTING SYSTEM, AND PROPERTY MANAGEMENT SYSTEM.
SUPPLIERS INTERNAL BUSINESS SYSTEMS HAVE NOT BEEN ASSESSED TO OR DO NOT COMPLY WITH THE TERMS AND CONDITIONS OF THE BUSINESS
SYSTEMS CLAUSE IN DFARS 252.242-7005. (COMMENT ON ANY NON-COMPLIANCE):
D. RESPONSIBLE SUPPLIER
CHECK AS APPLICABLE
SUPPLIER DEEMS ITSELF RESPONSIBLE IN ACCORDANCE WITH FAR 9.104 WHICH INCLUDES HAVING SATISFACTORY RECORDS OF INTEGRITY, PAST
PERFORMANCE, AND BUSINESS ETHICS; ADEQUATE FINANCIAL RESOURCES; TECHNICAL EQUIPMENT; FACILITIES; AND THE ORGANIZATIONAL
EXPERIENCE, SKILLS AND CONTROLS AVAILABLE OR OBTAINABLE TO PERFORM CONTRACTS AS AWARDED.
SUPPLIER POLICY OR PRACTICES PROHIBITS ENGAGING IN THE TRAFFICKING OR PERSONS, THE USE OF FORCED LABOR, OR THE PROCURING OF
COMMERCIAL SEX ACTS IN THE COUNTRY OR COUNTRIES IN WHICH IT CONDUCTS BUSINESS AND IS IN COMPLIANCE WITH 22 U.S.C 7104, FAR
52.222-50 AND EXECUTIVE ORDER DATED SEPTEMBER 25, 2012.
SUPPLIER QUALITY CERTIFICATIONS AND STANDARDS (INCLUDE TYPE AND EXPIRATION DATE AS APPLICABLE)
ISO
Form PU-125 (Rev. 01/13)
Previous editions are obsolete
[Source: XLS 9438 (Version date 12/12)
AS9100
OTHERS
Use/disclosure of data on this sheet is subject to the restrictions as stated
in this form’s directive, the SBSP, and the Corporate Purchasing Manual.
Page 8 of 14
SECTION V: FEDERAL ACQUISITION REGULATION (FAR) CERTIFICATIONS
THIS SECTION TO BE COMPLETED BY ALL SUPPLIERS
A. CERTIFICATION AND DISCLOSURE REGARDING PAYMENTS TO INFLUENCE CERTAIN FEDERAL TRANSACTIONS AS DESCRIBED UNDER FAR 52.20311/12:
CHECK ONLY ONE BOX
SUPPLIER DECLARES THEY ARE IN COMPLIANCE WITH 31 U.S.C. 1352 WHICH PROHIBITS A RECIPIENT OF A FEDERAL CONTRACT,
GRANT, LOAN OR COOPERATIVE AGREEMENT INCLUDING THE EXTENSION, CONTINUATION, RENEWAL AMENDMENT OR MODIFICATIONS
(“AWARD) FROM USING APPROPRIATED FUNDS TO PAY ANY PERSON FOR INFLUENCING OR ATTEMPTING TO INFLUENCE AN OFFICER OR
EMPLOYEE OF ANY AGENCY, A MEMBER OF CONGRESS, AN OFFICER OR EMPLOYEE OF CONGRESS, OR AN EMPLOYEE OF A MEMBER OF
CONGRESS IN CONNECTION WITH ANY COVERED FEDERAL ACTIONS. IN ADDITION, SUPPLIER DECLARES IT WILL OBTAIN THIS CERTIFICATION
FROM ITS SUPPLIERS FOR EVERY AWARD GREATER THAN $150,000 PRIOR TO MAKING SUCH AWARD, AND WILL REQUIRE FLOWDOWN TO
ALL SUB-TIER SUPPLIERS FOR CERTIFICATION PRIOR TO EACH AWARD GREATER THAN $150,000. SUPPLIER FURTHER DECLARES THAT IN THE
EVENT IT RECEIVES AN OFFICE OF MANAGEMENT AND BUDGET (OMB) STANDARD FORM LLL, DISCLOSURE LOBBYING ACTIVITIES (“SFLLL”) FROM A SUPPLIER AT ANY TIER IN CONNECTION WITH AN EXELIS INC. AWARD, OR AN UPDATE TO AN SF-LLL, SUPPLIER WILL PROVIDE
SUCH DISCLOSURE TO EXELIS INC. NOT LATER THAN 20 DAYS AFTER THE END OF THE MOST RECENTLY COMPLETED CALENDAR QUARTER.
OR
SUPPLIER DECLARES, UNDER LOBBYING DISCLOSURE ACT OF 1995, THEY HAVE, OR MAY, MAKE A LOBBYING CONTACT WITH
RESPECT TO AN EXELIS INC. AWARD THAT EXCEEDS $150,000 AND SUBMITS ATTACHED TO THIS CERTIFICATION OR WILL SUBMIT AS SOON
AS APPLICABLE, THE SF-LLL TO EXELIS INC. AS REQUIRED IN FAR 52.203-12(G), AND THAT SUPPLIER WILL PROVIDE UPDATE AS REQUIRED
BY 31 U.S.C. 1352 TO EXELIS INC. NOT LATER THAN 20 DAYS AFTER THE END OF THE MOST RECENTLY COMPLETED CALENDAR QUARTER.
B. CERTIFICATION REGARDING DEBARMENT, SUSPENSION, PROPOSED DEBARMENT AND OTHER RESPONSIBILITY MATTERS AS DESCRIBED UNDER
FAR 52.209-5:
A. THE OFFEROR CERTIFIES, TO THE BEST OF ITS KNOWLEDGE AND BELIEF, THAT:
i. THE OFFEROR AND/OR ANY OF ITS PRINCIPALS:
(1) ARE
, ARE NOT
PRESENTLY DEBARRED, SUSPENDED, PROPOSED FOR DEBARMENT, OR DECLARED INELIGIBLE FOR THE
AWARD OF CONTRACTS BY ANY FEDERAL AGENCY;
(2) HAVE
, HAVE NOT
WITHIN A THREE-YEAR PERIOD PRECEDING THIS OFFER, BEEN CONVICTED OF OR HAD A CIVIL
JUDGMENT RENDERED AGAINST THEM FOR: COMMISSION OF FRAUD OR A CRIMINAL OFFENSE IN CONNECTION WITH OBTAINING,
ATTEMPTING TO OBTAIN, OR PERFORMING A PUBLIC (FEDERAL. STATE OR LOCAL) CONTRACT OR SUBCONTRACT; VIOLATION OF
FEDERAL OR STATE ANTITRUST STATUTES RELATING TO THE SUBMISSION OF OFFERS; OR COMMISSION OF EMBEZZLEMENT, THEFT,
FORGERY, BRIBERY, FALSIFICATION OR DESTRUCTION OF RECORDS, MAKING FALSE STATEMENTS, TAX EVASION, OR RECEIVING
STOLEN PROPERTY; AND
(3) ARE
, ARE NOT
PRESENTLY INDICTED FOR, OR OTHERWISE ENUMERATED IN SUBDIVISION (A)(1)(I)(B) OF THIS
PROVISION.
(4) HAVE , HAVE NOT , WITHIN A THREE-YEAR PERIOD PRECEDING THIS OFFER, BEEN NOTIFIED OF ANY DELINQUENT FEDERAL
TAXES IN AN AMOUNT THAT EXCEEDS $3,000 FOR WHICH THE LIABILITY REMAINS UNSATISFIED.
ii. THE OFFEROR HAS
, HAS NOT
WITHIN A THREE-YEAR PERIOD PRECEDING THIS OFFEROR, HAD ONE OR MORE CONTRACTS
TERMINATED FOR DEFAULT BY ANY FEDERAL AGENCY.
Form PU-125 (Rev. 01/13)
Previous editions are obsolete
[Source: XLS 9438 (Version date 12/12)
Use/disclosure of data on this sheet is subject to the restrictions as stated
in this form’s directive, the SBSP, and the Corporate Purchasing Manual.
Page 9 of 14
iii. The offeror and/or any of its principals(1) Has
, Has Not
adequate financial resources to perform the contract, or the ability to obtain them
(see FAR 9.104-3(a))
(2) Are
, Are Not
able to comply with the required or proposed delivery or performance schedule,
taking into consideration all existing commercial and governmental business commitments;
(3) Has
, Has Not
a satisfactory performance record (see FAR 9.104-3(b) and Subpart 42.15). A
prospective contractor shall not be determined responsible or nonresponsible solely on the basis of a lack
of relevant performance history, except as provided in FAR 9.104-2;
(4) Has , Has Not
a satisfactory record of integrity and business ethics;
(5) Has
, Has Not
the necessary organization, experience, accounting and operational controls, and
technical skills, or the ability to obtain them (including, as appropriate, such elements as production
control procedures, property control systems, quality assurance measures, and safety programs applicable
to materials to be produced or services to be performed by the prospective contractor and
subcontractors). (See FAR 9.104-3 (a).)
(6) Has , Has Not
the necessary production, construction, and technical equipment and facilities, or the
ability to obtain them (see FAR 9.104-3(a)); and
(7) Are
, Are Not
otherwise qualified and eligible to receive an award under applicable laws and
regulations.
C.
PLACE OF PERFORMANCE AS DESCRIBED UNDER FAR 52.215-6:
SUPPLIER, IN THE PERFORMANCE OF ANY CONTRACT, INTENDS
, DOES NOT INTEND
TO USE ONE OR MORE PLANTS OR
FACILITIES LOCATED AT A DIFFERENT ADDRESS FROM THE ADDRESS OF THE SUPPLIER AS INDICATED ON THE TITLE PAGE OF THIS ANNUAL
SUPPLIER CERTIFICATION DOCUMENT.
IF SUPPLIER INTENDS TO USE ONE OR MORE PLANTS OR FACILITIES, AS STATED ABOVE, THE FOLLOWING INFORMATION IS REQUIRED.
FULL ADDRESS OF FACILITY
NAME/ADDRESS OF OWNER/OPERATOR OF
FACILITY IF OTHER THAN OFFEROR/QUOTER
IF FOREIGN MANUFACTURER, INDICATE
IS THIS SITE DDTC REGISTERED?
MLA# (ATTACH COPY OF MLA)
YES OR NO
D. CERTIFICATION REGARDING KNOWLEDGE OF CHILD LABOR FOR LISTED END PRODUCTS AS DESCRIBED UNDER FAR 52.222-18:
CHECK ONLY ONE BOX
SUPPLIER REPRESENTS THAT IT WILL NOT SUPPLY ANY END PRODUCT INCLUDED IN THE LIST OF PRODUCTS REQUIRING CONTRACTOR
CERTIFICATION BY COUNTRY OF ORIGIN AS TO FORCED OR INDENTURED CHILD LABOR.
SUPPLIER REPRESENTS THAT IT MAY SUPPLY AN END PRODUCT THAT WAS MINED, PRODUCED, OR MANUFACTURED IN THE
CORRESPONDING COUNTRY AS LISTED FOR THAT PRODUCT. THE SUPPLIER CERTIFIES THAT IT HAS MADE A GOOD FAITH EFFORT TO
DETERMINE WHETHER FORCED OR INDENTURED CHILD LABOR WAS USED TO MINE, PRODUCE, OR MANUFACTURE SUCH END PRODUCT.
ON THE BASIS OF THOSE EFFORTS, THE SUPPLIER CERTIFIES THAT IT IS NOT AWARE OF ANY SUCH USE OF CHILD LABOR.
THE FOLLOWING END PRODUCT(S) THAT MAY BE ACQUIRED ARE INCLUDED IN THE LIST OF PRODUCTS REQUIRING CONTRACTOR
CERTIFICATION AS TO FORCED OR INDENTURED CHILD LABOR, IDENTIFIED BY THEIR COUNTRY OF ORIGIN. THERE IS A REASONABLE
BASIS TO BELIEVE THAT LISTED END PRODUCTS FROM THE LISTED COUNTRIES OF ORIGIN MAY HAVE BEEN MINED, PRODUCED, OR
MANUFACTURED BY FORCED OR INDENTURED CHILD LABOR.
LISTED END PRODUCT
Form PU-125 (Rev. 01/13)
Previous editions are obsolete
[Source: XLS 9438 (Version date 12/12)
LISTED COUNTRIES OF ORIGIN
Use/disclosure of data on this sheet is subject to the restrictions as stated
in this form’s directive, the SBSP, and the Corporate Purchasing Manual.
Page 10 of 14
E.
PREVIOUS CONTRACTS AND COMPLIANCE REPORTS AS DESCRIBED UNDER FAR 52.222-22:
CHECK APPLICABLE BOXES IN STATEMENTS 1 & 2 OR SELECT EXEMPT OPTION AND PROVIDE EXPLANATION
SUPPLIER REPRESENTS THAT IT:
1. HAS , HAS NOT
PARTICIPATED IN A PREVIOUS CONTRACT OR SUBCONTRACT SUBJECT TO THE EQUAL OPPORTUNITY CLAUSE OF THIS
SOLICITATION AND
2.
HAS
OR
, HAS NOT
FILED ALL REQUIRED COMPLIANCE REPORTS.
SUPPLIER CERTIFIES THAT IT IS EXEMPT.
EXPLANATION:
F.
CERTIFICATION OF AFFIRMATIVE ACTION AS DESCRIBED UNDER FAR 52.222-25:
RESPOND TO ONLY ONE STATEMENT
1. SUPPLIER REPRESENTS THAT AT EACH ESTABLISHMENT, AFFIRMATIVE ACTION PROGRAMS REQUIRED BY THE RULES AND REGULATIONS OF
THE SECRETARY OF LABOR (41CFR 60-1 AND 60-2):
ARE DEVELOPED AND ARE ON FILE
ARE NOT DEVELOPED AND ARE NOT ON FILE
OR
2.
SUPPLIER HAS NOT PREVIOUSLY HAD CONTRACTS SUBJECT TO THE WRITTEN AFFIRMATIVE ACTION PROGRAMS REQUIREMENT OF THE
RULES AND REGULATIONS OF THE SECRETARY OF LABOR.
OR
3.
SUPPLIER CERTIFIES THAT IT IS EXEMPT FROM FILING REQUIREMENTS.
EXPLANATION:
G. BUY AMERICAN CERTIFICATE AS DESCRIBED UNDER FAR 52.225-2, -4, -6:
a.
SUPPLIER CERTIFIES THAT EACH END PRODUCT PROVIDED, EXCEPT THOSE LISTED BELOW, IS A U.S. DOMESTIC OR DESIGNATED COUNTRY END
PRODUCT AND THAT FOR OTHER THAN COTS ITEMS, THE SUPPLIER HAS CONSIDERED COMPONENTS OF UNKNOWN ORIGIN TO HAVE BEEN
MINED, PRODUCED, OR MANUFACTURED OUTSIDE THE UNITED STATES.
NON-U.S. DOMESTIC/NON-DESIGNATED COUNTRY END PRODUCTS:
ITEM NUMBER
COUNTRY OF ORIGIN
b.
SUPPLIER CERTIFIES THAT THE FOLLOWING ARE FREE TRADE AGREEMENT COUNTRY END PRODUCTS (OTHER THAN BAHRAINIAN,
MOROCCAN, OMANI, OR PERUVIAN END PRODUCTS) OR ISRAELI END PRODUCTS AS DEFINED IN THE CLAUSE 52.225-4 “BUY AMERICAN
ACT – FREE TRADE AGREEMENTS – ISRAELI TRADE ACT.”
FREE TRADE AGREEMENT COUNTRY OR ISRAELI END PRODUCTS:
ITEM NUMBER
COUNTRY OF ORIGIN
H. REPRESENTATION OF LIMITED RIGHTS DATA AND RESTRICTED COMPUTER SOFTWARE AS DESCRIBED UNDER FAR 52.227-15:
CHECK ONLY ONE BOX
SUPPLIER CERTIFIES THAT NONE OF THE DATA, TECHNICAL OR COMPUTER SOFTWARE, USED IN FULFILLING EXELIS INC.’S
REQUIREMENTS QUALIFIES AS LIMITED RIGHTS DATA OR RESTRICTED COMPUTER SOFTWARE.
Form PU-125 (Rev. 01/13)
Previous editions are obsolete
[Source: XLS 9438 (Version date 12/12)
Use/disclosure of data on this sheet is subject to the restrictions as stated
in this form’s directive, the SBSP, and the Corporate Purchasing Manual.
Page 11 of 14
SUPPLIER CERTIFIES THAT DATA, TECHNICAL OR COMPUTER SOFTWARE, USED IN FULFILLING EXELIS INC.’S REQUIREMENTS QUALIFIES
AS LIMITED RIGHTS DATA OR RESTRICTED COMPUTER SOFTWARE AS IDENTIFIED AS FOLLOWS:
______________________
SUPPLIER CERTIFIES THAT IT IS EXEMPT FROM FILING REQUIREMENTS BASED UPON
I.
LIMITATIONS ON PASS-THROUGH CHARGES:
OFFEROR REPRESENTS THAT IT WILL NOT SUBCONTRACT MORE THAN 70 PERCENT OF THE TOTAL COST OF THE WORK TO BE
PERFORMED UNDER ANY SUBCONTACT ISSUED BY EXELIS INC.; AND
OFFEROR ACKNOWLEDGES THAT SUBCONTRACTS ISSUED BY EXELIS INC. SHALL BE SUBJECT TO FAR 52.215-23 LIMITATIONS ON PASSTHROUGH CHARGES.
Form PU-125 (Rev. 01/13)
Previous editions are obsolete
[Source: XLS 9438 (Version date 12/12)
Use/disclosure of data on this sheet is subject to the restrictions as stated
in this form’s directive, the SBSP, and the Corporate Purchasing Manual.
Page 12 of 14
Section VI: Anti-Corruption Compliance Certification
this section to be completed by all suppliers
this THAT
section
to be U.S.
completed
by ,all
suppliers
THE FOREIGN CORRUPT PRACTICES ACT OF 1977 (“FCPA”) IS A CRIMINAL LAW OF THE U.S.
PROHIBITS
COMPANIES
THEIR
EMPLOYEES
AND AGENTS FROM CORRUPTLY GIVING, OFFERING, PROMISING, OR AUTHORIZING ANYTHING OF VALUE TO FOREIGN (NON-U.S.) OFFICIALS OR
FOREIGN POLITICAL PARTIES, OFFICIALS OR CANDIDATES, FOR THE PURPOSE OF INFLUENCING THEM TO MISUSE THEIR OFFICIAL CAPACITY TO OBTAIN,
KEEP, OR DIRECT BUSINESS OR GAIN ANY IMPROPER BUSINESS ADVANTAGE. THE FCPA ALSO PROHIBITS INTENTIONAL MISREPRESENTATIONS IN A
COMPANY’S BOOKS AND RECORDS AND REQUIRES THAT A COMPANY’S BOOKS, RECORDS AND ACCOUNTS BE MAINTAINED IN REASONABLE DETAIL
ACCURATELY REPRESENTING TRANSACTIONS OR ANY PAYMENT. IN ADDITION TO PROHIBITING CORRUPT PAYMENTS TO FOREIGN OFFICIALS, THE FCPA
ALSO FORBIDS OFFERING OR PAYING ANYTHING OF VALUE TO ANY PERSON OR ENTITY (FOR EXAMPLE, A THIRD-PARTY) WHEN IT IS KNOWN THAT ALL OR
PART OF THE PAYMENT WILL BE TRANSMITTED TO A FOREIGN OFFICIAL FOR THE IMPROPER PURPOSES MENTIONED ABOVE.
THE UK BRIBERY ACT (“BRIBERY ACT”) SETS OUT A RANGE OF CRIMINAL OFFENCES IN CONNECTION WITH CORRUPT PAYMENTS MADE TO PUBLIC
OFFICIALS AND PRIVATE PARTIES ANYWHERE IN THE WORLD. FACILITATION PAYMENTS ARE PROHIBITED UNDER THE BRIBERY ACT. THE BRIBERY ACT
ALSO MAKES IT AN OFFENCE TO REQUEST, AGREE TO RECEIVE, OR TO ACCEPT A BRIBE.
THE FCPA AND BRIBERY ACT APPLY TO EXELIS INC.’S OPERATIONS WORLDWIDE, ITS EMPLOYEES AND TO ALL PERSONS AND ENTITIES, WHEREVER
LOCATED, ACTING ON BEHALF OF EXELIS INC., SUCH AS SUPPLIERS, REPRESENTATIVES, CONSULTANTS, AND AGENTS. COMPANIES THAT VIOLATE THE
FCPA AND BRIBERY ACT MAY BE SUBJECT TO EXTENSIVE FINANCIAL PENALTIES. INDIVIDUAL OFFICERS, DIRECTORS, EMPLOYEES, MARKETING
REPRESENTATIVES, CONSULTANTS, SUPPLIERS OR AGENTS FOUND TO HAVE WILLFULLY VIOLATED THE FCPA, BRIBERY ACT OR OTHER LOCAL ANTICORRUPTION LAW MAY BE FINED AND IMPRISONED FOR SUCH VIOLATIONS.
CHECK ONLY ONE BOX
SUPPLIER IS A U.S. COMPANY OPERATING IN THE UNITED STATES ONLY
SUPPLIER IS A U.S. OR FOREIGN (NON-U.S.) COMPANY AND OPERATES OUTSIDE THE UNITED STATES
COMPLIANCE WITH ANTI-CORRUPTION STATUES AND REGULATIONS - READ AND SIGN BELOW
SUPPLIER WARRANTS AND REPRESENTS THAT IT IS FAMILIAR WITH THE REQUIREMENTS OF THE U.S. FOREIGN CORRUPT PRACTICES ACT (“FCPA”),
THE U.K. BRIBERY ACT, AND ANY APPLICABLE LOCAL OR FOREIGN LAWS, ORDINANCES, AND REGULATIONS REGARDING PAYMENTS, GRATUITIES, OR
BRIBES TO GOVERNMENT PERSONNEL AND CERTIFIES TO THE BEST OF ITS KNOWLEDGE, IT IS NOT AWARE OF ANY CURRENT OR PAST ACTIVITY BY
SUPPLIER, ITS EMPLOYEES OR THIRD-PARTIES RETAINED BY SUPPLIER THAT WOULD BE IN VIOLATION OF THE FCPA, BRIBERY ACT OR OTHER
APPLICABLE LOCAL LAW.
SUPPLIER STATES AND ACKNOWLEDGES THAT IT IS THE POLICY OF SUPPLIER TO COMPLY STRICTLY WITH THE LAWS AND REGULATIONS OF THE UNITED
STATES, AND OTHER COUNTRIES IN WHICH IT DOES BUSINESS AND TO CONFORM TO THE EXELIS CODE OF CONDUCT AS IT RELATES TO INTERMEDIARIES,
IN ITS CURRENT FORM AND AS IT MAY BE AMENDED FROM TIME TO TIME. SUPPLIER WILL ENSURE THAT ITS OWNERS, DIRECTORS, OFFICERS,
EMPLOYEES, AND IF AUTHORIZED, ANY AGENTS, OR OTHER PERSONS ACTING ON BEHALF OF SUPPLIER COMPLY WITH THIS POLICY. SUPPLIER WILL
IMMEDIATELY NOTIFY EXELIS IF IT HAS REASON TO BELIEVE THE STATEMENTS IN THIS CERTIFICATION TO BE UNTRUE, INACCURATE OR INCOMPLETE.
PRINTED NAME AND TITLE
COMPANY NAME
SIGNATURE
DATE
Form PU-125 (Rev. 01/13)
Previous editions are obsolete
[Source: XLS 9438 (Version date 12/12)
Use/disclosure of data on this sheet is subject to the restrictions as stated
in this form’s directive, the SBSP, and the Corporate Purchasing Manual.
Page 13 of 14
CERTIFICATION
THIS SECTION TO BE COMPLETED BY ALL SUPPLIERS
AS A DULY AUTHORIZED REPRESENTATIVE OF THE COMPANY DENOTED BELOW, I CERTIFY THE ACCURACY OF ALL STATEMENTS HEREIN, ACKNOWLEDGE
AN AWARENESS OF THE U.S. GOVERNMENT’S CONTRACTING AND SUBCONTRACTING PROGRAMS AND CONFIRM THAT OUR COMPANY WILL COMPLY
WITH ALL STATEMENTS HEREIN.
I UNDERSTAND THAT THIS CERTIFICATION SHALL APPLY TO ALL REQUESTS FOR QUOTATIONS, PURCHASE ORDERS OR SUBCONTRACTS RECEIVED FROM
EXELIS INC AND UNDERSTAND THAT I AM RESPONSIBLE FOR NOTIFYING EXELIS INC. OF ANY CHANGES IN STATUS AFFECTING THIS CERTIFICATION.
I FURTHER ACKNOWLEDGE THAT WHERE INFORMATION MUST BE EXCHANGED BETWEEN OUR COMPANY AND EXELIS INC., REGARDLESS OF THE MEDIA
OR METHOD USED TO EXCHANGE INFORMATION, WE SHALL PRESERVE IN CONFIDENCE EXELIS INC.’S INFORMATION AND SHALL, UNLESS OTHERWISE
AUTHORIZED IN WRITING BY AN AUTHORIZED AGENT OF EXELIS INC., PREVENT DISCLOSURE TO THIRD PARTIES. WE SHALL FURTHER RESTRICT
DISCLOSURE OF EXELIS INC.’S INFORMATION TO OUR EMPLOYEES TO A NEED TO KNOW BASIS AND WILL ADVISE THE RESTRICTIONS OF DISCLOSURE AND
USE. IF WE DETERMINE AN UNAUTHORIZED USE OR DISCLOSURE OF EXELIS INC.’S INFORMATION, WE SHALL PROMPTLY NOTIFY EXELIS INC. OF THE
DISCLOSURE AND SHALL ENDEAVOR TO PREVENT FURTHER UNAUTHORIZED USE OR DISCLOSURE.
PRINTED NAME AND TITLE
COMPANY NAME
SIGNATURE
DATE
Form PU-125 (Rev. 01/13)
Previous editions are obsolete
[Source: XLS 9438 (Version date 12/12)
Use/disclosure of data on this sheet is subject to the restrictions as stated
in this form’s directive, the SBSP, and the Corporate Purchasing Manual.
Page 14 of 14