DD Form 441-1 Appendage to Department of Defense Security Agreement

APPENDAGE TO DEPARTMENT OF DEFENSE SECURITY AGREEMENT

OMB No. 0704-0194
OMB approval expires

PLEASE DO NOT RETURN YOUR FORM TO THE ORGANIZATION IN THE PARAGRAPH BELOW. RETURN COMPLETED FORM TO YOUR RESPECTIVE
COGNIZANT SECURITY OFFICE.
The public reporting burden for this collection of information is estimated to average 10 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 this burden estimate or any other aspect of this collection of information,
including suggestions for reducing the burden, to the Department of Defense, Washington Headquarters Services, Executive Services Directorate, Directives Division, Office of Information
Management, 4800 Mark Center Drive, East Tower, Suite 02G09, Alexandria, VA 22350-3100 (0704-0194). 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. DISCLOSUE: Voluntary, however, if the form is not
provided a facility clearance cannot be issued.

It is further agreed, on this

day of

by and between the United States of America

,

through the Defense Security Service, acting for the Department of Defense, hereinafter called the Government, and
which has entered into the Security Agreement to which this
appendix is made a part that the branches and/or facilities listed below, owned and/or operated by said contractor are included in
and covered by the provisions of the said Security Agreement, and Certificate Pertaining to Foreign Interests, Standard Form 328.
NAME OF PLANT OR FACILITY

NUMBER AND STREET ADDRESS

N E E D S

D D

CITY AND STATE

6 7

CONTRACTOR (Typed Name)

THE UNITED STATES OF AMERICA
BY (Signature of Government Representative)

BY (Signature of Authorized Contractor Representative)

AUTHORIZED REPRESENTATIVE OF THE GOVERNMENT
(Typed Name of Government Agency)

TITLE (of Authorized Contractor Representative)

ADDRESS

DD FORM 441-1, 20120501 DRAFT

PREVIOUS EDITION IS OBSOLETE.

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