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FOREIGN OWNERSHIP, CONTROL, OR INFLUENCE (FOCI) DETERMINATION DOCUMENTS (5-99) - page 4 / 16

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SAMPLE FORMAT

REPRESENTATIVE OF FOREIGN INTEREST STATEMENT

(This form is to be initially submitted, as part of the FOCI package, by the contractor or subcontractor. The form should be completed and executed by each employee who holds a position with a foreign interest and who possesses or is being processed for a DOE security clearance who become an RFI or whose status as an RFI changes in a manner that would make him/her ineligible for a security clearance.)

Name and address of the foreign firm:

Nature of business of foreign firm:

Details of ownership of foreign firm:

The specific relationship between the foreign firm and the United States firm:

Percentage of time devoted for foreign firm:

Summary of duties with the United States firm. Provide detailed information as well as title of position:

Summary of duties with the foreign firm. Provide detailed information as well as title of position:

Have you ever registered as an Agent of a foreign government as detailed in 18 U.S.D. 219? If so, please provide details:

Communist affiliation: if none, so state:

CERTIFICATION:

I recognize my special responsibility to protect classified information from disclosure to any unauthorized person, foreign or domestic.

TYPED OR PRINTED NAME:

FULL NAME:

DATE:

(Signature)

SSN:

FACILITY:

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