GENERAL DYNAMICS
CERTIFICATION AND REPRESENTATION REGARDING FOREIGN
OWNERSHIP, CONTROL OR INFLUENCE (FOCI)
THIS FORM MUST BE COMPLETED AND SIGNED BY AN OFFICER, OWNER OR EMPOWERED OFFICIAL OF OFFEROR.
IF ANY OF THE INFORMATION IN THIS DOCUMENT CHANGES, OFFEROR MUST PROMPTLY NOTIFY EB.
Section 1 – Business Information
1. Legal Entity Name:
_______________________________________________________
3. Manufacturing / Performance Address (Number, Street) (for work
proposed to be performed hereunder):
DBA or Division (if applicable):
_______________________________________________________
_______________________________________________________
2. Principal Address (Number, Street):
_______________________________________________________
City (Town), State & Postal Code (Full 9 Digits for US Zip Codes):
_______________________________________________________
Country:
__________________________
POC Email:
__________________________
Telephone:
__________________________
Facsimile:
__________________________
Offeror’s business status (Check one):
Individual / Sole Proprietor
Corporation
Government Agency
Non-Profit Organization
City (Town), State & Postal Code (Full 9 Digits for US Zip Codes):
_______________________________________________________
Country:
__________________________
POC Email:
__________________________
Telephone:
__________________________
Facsimile:
__________________________
Partnership
Private Foundation
Trust/Estate
Non-US Entity
The Offeror’s Commercial And Government Entity (CAGE) is as follows:
CAGE Code: _______________
No CAGE Code
Section 2 – Certifications and Representations regarding Foreign Ownership Control OR
Influence (FOCI)
Instructions:
US Companies –
Canadian Companies –
UK and Australian Companies –
Other Non-US Companies –
Complete Parts (1) – (8) and, for access to Naval Nuclear Propulsion Information (NNPI), Part (10)
Complete Parts (1) – (5) and (11)
Complete Parts (1) – (4) and (9)
Complete Parts (1) – (4)
(1) Offeror is organized and existing under the laws of _________________________ (State / Province) in ________________________ (Country).
(2) Ownership and / or Affiliate Status:
Offeror represents and certifies that it:
Is not owned or controlled, in whole or in party, by another company or entity.
Is
Is not a division or subsidiary of another company or entity.
Is
Is not owned or controlled, in whole or in part, by the government of a country. If it is, name of country: ________________________
Is
If Offeror is owned or controlled by another company or entity or is a division or subsidiary of another company or entity, Offeror must provide the
following information (attached additional pages if needed):
Name of Immediate Parent:
Address of Immediate Parent:
Place of Incorporation:
EB Form No. 84-03-2205 Rev 11/2012
(Replaces Prior Rev. 4/2012)
75 Eastern Point Road, Dept. 330, Groton, CT 06340
PAGE 1 of 4
Offeror’s relationship to Immediate Parent:
Name of Ultimate Parent:
Address of Ultimate Parent:
Place of Incorporation:
Offeror’s relationship to Ultimate Parent:
(3) Information Regarding Offeror’s Employees:
Does Offeror employ dual nationals and / or third country nationals?
Yes
No
If yes to the preceding question, do these employees require access to any technical data or hardware?
Yes
No
If yes to the preceding question, in the space below provide the nationality or dual nationality of each such employee.
_______________________________________________________________________________________________________________________.
If no, does Offeror have an Access Control Plan/Technology Control Plan preventing intentional or unintentional access to controlled EB technical
data and products?
Yes
No
(4) Control of Access to U.S. Technical Data Other Than Naval Nuclear Propulsion Information (NNPI):
The Offeror:
Does not have a written Access Control Plan/Technology Control Plan (ACP/TCP) to prevent the unauthorized export or
Has
disclosure of Technical Data, regardless of whether such export or disclosure occurs within the U.S. or abroad. Release to unauthorized persons
includes unauthorized employees, unauthorized foreign nationals and/or foreign interests, as well as release to the public.
(5) (U.S. and Canadian offerors only). U.S./Canada Joint Certification Program (JCP) certification through the Defense Logistics Information Service
(DLIS):
JCP Certification establishes the eligibility of a U.S. or Canadian contractor to receive certain technical data subject to U.S. and/or Canadian export
control laws and regulations. For DLIS FAQ and application form, visit http://www.dlis.dla.mil/jcp/.
The Offeror (check one only):
a)
Has an active JCP certification. Certification number: _______________. Expiration Date: _______________.
b)
Does not have an active JCP certification.
c)
Has applied for a JCP certification through DLIS and will notify EB promptly of its certification number and expiration date when
Offeror’s certification is in place.
(6) (U.S. offerors only). Department of Defense (DoD) Directives on Control of Technical Data (Note: DoD Directives can be accessed at
http://www.dtic.mil/whs/directives/corres/dir.html):
The Offeror:
Has not read DoD Directive 5230.24, “Distribution Statements on Technical Documents”, and DoD Directive 5230.25,
Has
“Withholding of Unclassified Technical Data From Public Disclosure,” and if it has;
Does not agree to comply with the applicable requirements of DoD Directives 5230.24 and 5330.25.
Agrees
(7) (U.S. offerors only). U.S. State Department Registration:
The Offeror:
Is not registered as a manufacturer or exporter of defense articles or provider of defense services pursuant to the International
Is
Traffic in Arms Regulations (ITAR), 22 CFR 122.
Is not registered as a broker per ITAR Part 129.
Is
If applicable, Offeror represents that its registration per this section 7 is in effect until ____________________.
(8) (U.S. offerors only). Foreign Ownership, Control or Influence (FOCI):
For the purposes of this section, “Foreign National” and “Foreign Interest” shall have the same meaning as defined in OPNAVINST N9210.3.
“Significant Interest” shall have the meaning given it in the clause at DFARS 252.209-7001.
EB Form No. 84-03-2205 Rev 11/2012
(Replaces Prior Rev. 4/2012)
75 Eastern Point Road, Dept. 330, Groton, CT 06340
PAGE 2 of 4
An Offeror is considered to be subject to FOCI if –

It is owned or controlled by a “Foreign National” or “Foreign Interest”; or

A “Foreign National” or “Foreign Interest” has a “Significant Interest” in Offeror’s company or any parent of Offeror; or

It is in partnership with a “Foreign National” or “Foreign Interest”.
(a) For each company or entity identified in this form, Offeror represents to EB that a foreign person(s), foreign entity, or foreign government,
individually or collectively, holds (Check all that apply):
Ownership of or a beneficial interest in at least 5 percent of such entity’s securities. Beneficial interest includes holding 5% or more of
Any class of the company’s securities in “nominee shares,” “street names,” or some other method of holding securities that does not disclose
The beneficial owner;
A management position in the firm, such as a director or officer;
The ability to control or influence the election, appointment, or tenure of directors or officers in the company;
Ownership of 10 percent or more of the assets of a firm such as equipment, buildings, real estate, or other tangible assets;
50% or more of the indebtedness of a firm.
If Offeror checked any of the boxes in 8(a), provide specific details including nationality of such owners, controllers, or interests: _______________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
(b) Does any foreign person(s), foreign entity, or any government, have the power, direct or indirect, whether or not exercised, and whether or not
exercisable through ownership of the company’s securities, by contractual arrangements or other means, to direct or decide matters affecting the
management or operations of any of the companies or entities identified in this form, in a manner that might result in unauthorized access to
U.S. technical data or information or adversely affect the performance of classified and/or unclassified contracts?
Yes
No
If yes to the preceding question, provide specific details: __________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
(c) If the certifying company is subject to FOCI and is a US entity, is there a Proxy Agreement, Special Security Agreement and/or a Government
Security Committee in place at the request of Defense Security Service (DSS) (See
https://www.dss.mil/GW/ShowBinary/DSS/isp/foci/foci_faqs.html)?
Yes
No
If yes to the preceding question, provide specific details: __________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
(9) (U.K. & Australian offerors only). Verification of United Kingdom and Australian Companies’ Eligibility to Participate in US-UK Defense Trade
Cooperation Treaty (effective 4/20/2012) or US-Australia Defense Trade Cooperation Treaty (effective date to be announced):
The U.S. State Department’s Treaty Reference System (TRS) assists U.S. exporters in confirming whether a UK or Australian company is a member
of the UK or Australian Approved Communities (AC), and is therefore an eligible recipient of items exported pursuant to the exemptions created by
the Treaties. AC members are assigned an Approved Community Identification Number (ACID) once approved for membership in the community.
With the ACID, U.S. exporters can confirm AC membership prior to export by entering the ACID into TRS at https://trs.pmddtc.state.gov.
Offeror’s Approved Community Identification Number (ACID): ____________________________________.
(10) (U.S. Offerors that require access to NNPI only). Control of Access to Naval Nuclear Propulsion Information (NNPI):
The Offeror (complete each line below):
(a)
Has not read OPNAVINST N9210.3 (excluding Table 2) and, if EB approves the Offeror for access to technical data
Has
including NNPI, it;
(1)
Does not agree to comply with the applicable requirements of that publication including the more stringent
Agrees
Requirements for controlling access to and disclosure of NNPI.
(2)
Does not have a written Access Control Plan/Technology Control Plan (ACP/TCP) that complies with
Has
OPNAVINST N9210.3 and (A) appropriately safeguards NNPI from unauthorized actual, potential, or inadvertent release in any
form, classified or unclassified, and (B) restricts access to NNPI to U.S. citizens who are not “Representatives of a Foreign Interest”
and who have a “need-to-know,” as such quoted terms are defined in OPNAVINST N9210.3.
(11) (Canadian Offerors only):
Definitions:
“Canadian-Registered Person” means “any Canadian national (including Canadian business entities organized under the laws of Canada), dual
citizen of Canada and a third country (subject to §126.1), and permanent resident registered in Canada in accordance with the Canadian Defence
EB Form No. 84-03-2205 Rev 11/2012
(Replaces Prior Rev. 4/2012)
75 Eastern Point Road, Dept. 330, Groton, CT 06340
PAGE 3 of 4
Production Act, and such other Canadian Crown Corporations” as may be identified by the U.S. International Traffic in Arms Regulations (22 CFR
120-130).
(a) Name and address of all Offeror entities / locations which require access to technical data or defense services: ____________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
(b) The Offeror is (Check one):
A Canadian Federal or Provincial governmental authority acting in an official capacity; or,
A “Canadian-registered person” in accordance with the Canadian Defence Production Act; in which case, Offeror’s registration number is
_______________ OR Offeror’s application for registration in Canada was / will be made on ________________.
(c) Non-Canadian-registered persons (other than U.S. citizens working on this project / program), whether within Offeror’s company or otherwise,
Will not require access to technical data or commodities.
Will
(d) If subcontractors will be required to perform work, such subcontractors:
Will not require access to U.S. technical data.
Will
If subcontractors will require access to U.S. technical data, identify such subcontractors by company name and address here: ___________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
Section 3: AUTHORIZED SIGNATURE OF OFFEROR
Certification by an Official of Offeror or Offeror’s Authorized Representative:
By submitting this information, I am attesting to the accuracy of the information contained herein. I understand that I may be subject to penalties
imposed by the United States Government if I misrepresent any of the representations or certifications herein. I further acknowledge on behalf of
Offeror that EB shall rely on the information provided by Offeror herein and that if any of Offeror’s representations herein change during the period
of performance, Offeror shall provide immediate written notice to the EB’s representative to whom this document was originally provided. By
signing below, I certify that I am an Officer, Owner or Empowered Official of Offeror duly authorized to sign this document on behalf of Offeror and
that to the best of my knowledge, the information provided in this document is current, accurate, and complete as of the date set forth below.
__________________________________________________________
__________________________________________________________
Signature of Offeror or Offeror’s Authorized Representative
Offeror’s Company Name
__________________________________________________________
__________________________________________________________
Printed Name and Title of Signatory
Company Address
_____________________________
__________________________
Telephone:
Date
EB Form No. 84-03-2205 Rev 11/2012
(Replaces Prior Rev. 4/2012)
75 Eastern Point Road, Dept. 330, Groton, CT 06340
__________________________
Facsimile:
PAGE 4 of 4