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FOREIGN OWNERSHIP, CONTROL, OR INFLUENCE (FOCI) DETERMINATION DOCUMENTS (5-99) - page 6 / 16

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Company’s Current Legal Name, Address, and Phone Number of Company’s Principal Executive Offices:

List ALL

1,2

Owners, Officers, Directors and Executive Personnel (OODEPs) Other names used (e.g., doing business as:)

Page of Date Submitted:

Tax Identification No.

Date Company was Incorporated:

State of Incorporation

(Must provide any name or address change of the Company’s principal executive office and dates) of change during past 10 years on the Attachment page.)

Organization Status:

  • Corporation

  • Sole Proprietorship

  • General

Partnership:

  • Limited

  • Other

Stock Ownership:

  • Privately-Owned

  • Publicly-Traded

  • Subsidiary of :

NAME (First Name, Initial, Last Name)

POSITION TITLES

IF OWNER,

CLEARANCE HELD

% OF

SSN

AND/OR BEING

OWNERSHIP

OBTAINED AND

ISSUING AGENCY

CITIZENSHIP

Facility Security Officer

1The above information, i.e., name, titles, etc., must be provided for the following: (a) the proprietor of a sole proprietorship; (b) all individuals managing the business affairs of a corporation . In most cases, these individuals are identified in the Articles of Incorporation By-Laws and include the Board of Directors, President, Secretary, and Treasurer; (c) the General Partner(s) of a Limited Partnership; and (d) all partners of a General Partnership. In addition, privately-held entities must provide the above information, i.e., name, titles, etc., for all owners, and also provide the percentage of issued stock/shares held by each owner. ---------------- List certified correct by: 2

Typed or Printed Name and Signature

Title

Date

(5/99)

6

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