UNCLASSIFIED
FOIA CONFIDENTIAL TREATMENT REQUESTED – PORTIONS OF THE EXHIBIT MARKED BY [**Redacted**] HAVE BEEN OMITTED | |
PURSUANT TO A REQUEST FOR CONFIDENTIAL TREATMENT FILED SEPARATELY WITH THE SECURITIES AND EXCHANGE COMMISSION | Exhibit 10.4
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UNCLASSIFIED
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AMEMDMENT OF SOLICIATION/MODIFICATION OF CONTRACT |
| 1 | 4 | ||||||
2. AMENDMENT/MODIFICATION NO. | 3. EFFECTIVE DATE | 4. REQUISITION/PURCHASE REO. NO. | 5. PROJECT NO. (If applicable) | ||||||
P00044 | 06/09/2017 | See Schedule |
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6. ISSUED BY | CODE | [**REDACTED**] | 7. ADMINISTERED BY (If other than Item 6) | CODE | [**REDACTED**] | ||||
[**REDACTED**] [**REDACTED**] [**REDACTED**] [**REDACTED**] | [**REDACTED**] [**REDACTED**] [**REDACTED**] [**REDACTED**] | ||||||||
8. NAME AND ADDRESS OF CONTRACTOR (No., street, county, State and ZIP Code) DIGITALGLOBE, INC. Attn: [**REDACTED**] 1300 W 120TH AVENUE WESTMINSTER CO 80234 |
| 9A. AMENDMENT OF SOLICITATION NO. | |||||||
| 9B. DATED (SEE ITEM 11) | ||||||||
X | 10A. MODIFICATION OF CONTRACT/ORDER NO. HM021013CN002 | ||||||||
CODE 1CGQ7 | FACILITY CODE |
| 10B. DATED (SEE ITEM 13) 07/30/2013 | ||||||
11. THIS ITEM ONLY APPLIES TO AMENDMENTS OF SOLICITATIONS |
☐ The above numbered solicitation is amended as set forth in Item 14. The hour and date specified for receipt of Offers ☐ is extended. ☐ is not extended.
Offers must acknowledge receipt of this amendment prior to the hour and date specified in the solicitation or as amended, by one of the following methods: (a) By completing Items 8 and 15, and returning copies of the amendment; (b) By acknowledging receipt of this amendment on each copy of the offer submitted; or (c) By separate letter or telegram which includes a reference to the solicitation and amendment numbers. FAILURE OF YOUR ACKNOWLEDGEMENT TO BE RECEIVED AT THE PLACE DESIGNATED FOR THE RECEIPT OF OFFERS PRIOR TO THE HOUR AND DATE SPECIFIED MAY RESULT IN REJECTION OF YOUR OFFER If by virtue of this amendment you desire to change an offer already submitted, such change may be made by telegram or letter, provided each telegram or letter makes reference to the solicitation and this amendment and is received prior to the opening hour and date specified.
12. ACCOUNTING AND APPROPRIATION DATA (If required)
See Schedule | Net Increase: | [**REDACTED**] | |
13. THIS ITEM ONLY APPLIES TO MODIFICATION OF CONTRACTS/ORDERS. IT MODIFIES THE CONTRACT/ORDER NO. AS DESCRIBED IN ITEM 14. | |||
CHECK ONE | A. THIS CHANGE ORDER IS ISSUED PURSUANT TO: (Specify authority) THE CHANGES SET FORTH IN ITEM 14 ARE MADE IN THE CONTRACT ORDER NO. IN ITEM 10A. | ||
| B. THE ABOVE NUMBERED CONTRACT/ORDER IS MODIFIED TO REFLECT THE ADMINISTRATIVE CHANGES (such as changes in paying office, appropriation date, etc.) SET FORTH IN ITEM 14, PURSUANT TO THE AUTHORITY OF FAR 43.103(b). | ||
| C. THIS SUPPLEMENTAL AGREEMENT IS ENTERED INTO PURSUANT TO AUTHORITY OF: | ||
X | D. OTHER (Specify type of modification and authority) Incremental Funding IAW Paragraph B .l0 | ||
E. IMPORTANT: | Contractor ☒ is not. ☐ is required to sign this document and return copies to the issuing office. |
14. DESCRIPTION OF AMENDMENT/MODIFICATION (Organized by UCF section headings, including solicitation/contract subject matter where feasible.)
Tax ID Number: 31-1420852
DUNS Number:   ###-###-####
The purpose of this modification is to provide incremental funding in the amount of [**REDACTED**] under contract line item (CLIN) 0601, Service Level Agreement for Pixel & Imagery Acquisition/ Operations (Baseline Collection Capacity). The total funding obligated under the contract increases by [**REDACTED**] from [**REDACTED**] to [**REDACTED**].
The estimated CLIN 0601 Service Level Agreement funds exhaustion date is 15-July-2017.
The total value of the Contract remains unchanged.
Continued...
Except as provided herein, all terms and conditions of the document referenced in Item 9 A or 10A, as heretofore changed, remains unchanged and in full force and effect.
15A. NAME AND TITLE OF SIGNER (Type or print) [**REDACTED**] |
| 16A. NAME AND TITLE OF CONTRACTING OFFICER (Type or print) [**REDACTED**] |
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15B. CONTRACTOR/OFFEROR [**REDACTED**] | 15C. DATE SIGNED [**REDACTED**] | 16b. UNITED STATES OF AMERICA [**REDACTED**] (Signature of Contracting Officer) | 16C. DATE SIGNED | |
(Signature of person authorized to sign) |
| [**REDACTED**] |
NSN 7540-01-152-8070 | STANDARD FORM 30 (REV. 10-83) Prescribed by GSA |
| FAR (48 CFR) 53.243 |
UNCLASSIFIED
UNCLASSIFIED
CONTINUATION SHEET | REFERENCE NO. OF DOCUMENT BEING CONTINUED HM021013CN002/P00044 | PAGE | OF |
2 | 4 |
NAME OF OFFEROR OR CONTRACTOR
DIGITALGLOBE, INC.
ITEM NO. (A) | SUPPLIES/SERVICES (B) | QUANTITY (C) | UNIT (D) | UNIT PRICE (E) | AMOUNT (F) |
|
1. Under Section B, Supplies or Services and Prices/Costs, Paragraph B.7 Total Contract Price/Total Contract Funding, (change pages 22 and 23 are attached hereto):
a CLIN Series 0600, Contract Year 7:
(1) Under CLIN 0601, the Obligated Amount column is increased by [**REDACTED**] from [**REDACTED**] to [**REDACTED**]. The Unfunded Amount column is decreased by [**REDACTED**] from [**REDACTED**] to [**REDACTED**]. The Maximum Total Price column is unchanged.
(2) Under Subtotal Contract Year 7, the Obligated Amount column is increased by [**REDACTED**] from [**REDACTED**] to [**REDACTED**]. The Unfunded Amount column is decreased by [**REDACTED**] from [**REDACTED**] to [**REDACTED**]. The Maximum Total Price column is unchanged.
b. Under Total Contract Value with Options, the Obligated Amount column is increased by [**REDACTED**] to [**REDACTED**]. The Unfunded Amount column is decreased by [**REDACTED**] from [**REDACTED**] to [**REDACTED**]. The Maximum Total Price column is unchanged.
2. Under Section G, Contract Administration Data, Paragraph G.6, Accounting and Appropriation Data, the table is revised to reflect the [**REDACTED**] obligation under existing CLIN 0601 informational Sub-CLIN 060103 and Sub-CLIN 060104. Change page 34a is attached hereto.
Discount Terms:
Net 30
Payment: [**REDACTED**] [**REDACTED**] [**REDACTED**] [**REDACTED**] [**REDACTED**] [**REDACTED**] FOB: Destination Period of Performance: 09/01/2013 to 08/31/2017
Continued ... |
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NSN 7540-01-152-8067 | OPTIONAL FORM 336 (4-86) |
| Sponsored by GSA |
UNCLASSIFIED
UNCLASSIFIED
CONTINUATION SHEET | REFERENCE NO. OF DOCUMENT BEING CONTINUED HM021013CN002/P00044 | PAGE | OF |
3 | 4 |
NAME OF OFFEROR OR CONTRACTOR
DIGITALGLOBE, INC.
ITEM NO. (A) | SUPPLIES/SERVICES (B) | QUANTITY (C) | UNIT (D) | UNIT PRICE (E) | AMOUNT (F) |
| Change Item 0601 to read as follows (amount shown is the obligated amount):
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0601 | Commercial Satellite Imagery - Service Level Agreement For Pixel & Imagery Acquisition/Operations (Baseline Collection Capacity). $300,000,000.00 per year CLIN VALUE: [**REDACTED**] Product/Service Code: 7640 Product/Service Description: MAPS, ATLASES, CHARTS, & GLOBES
Period of Performance: 09/01/2016 to 08/31/2017
Change Item 060103 to read as follows (amount shown is the obligated amount):
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| [**REDACTED**]
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060103 | Commercial Satellite Imagery - SLA Funding. CLIN VALUE: [**REDACTED**] Product/Service Code: 7640 Product/Service Description: MAPS, ATLASES, CHARTS, & GLOBES Requisition No: NSX8G86295AS01, NSX8G86341AS11, NSX8G86362AS14, NSX8G87020AS15, NSX8G87131AS19, NSX8G87157AS21
Accounting Info: [**REDACTED**] Funded: [**REDACTED**] Accounting Info: [**REDACTED**] Funded: [**REDACTED**] Period of Performance: 09/01/2016 to 08/31/2017
Change Item 060104 to read as follows (amount shown is the obligated amount):
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| [**REDACTED**]
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060104 | Commercial Satellite Imagery - SLA Funding. CLIN VALUE: [**REDACTED**] Product/Service Code: 7640 Product/Service Description: MAPS, ATLASES, CHARTS, & GLOBES Requisition No: NSX8G86295AS01, NSX8G86341AS11, NSX8G86362AS14, NSX8G87020AS15, NSX8G87072AS17, NSX8G87117AS18, NSX8G87131AS19, NSX8G87157AS21
Accounting Info: [**REDACTED**] Funded: [**REDACTED**] Accounting Info: Continued ...
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| [**REDACTED**] |
NSN 7540-01-152-8067 | OPTIONAL FORM 336 (4-86) |
| Sponsored by GSA |
UNCLASSIFIED
UNCLASSIFIED
CONTINUATION SHEET | REFERENCE NO. OF DOCUMENT BEING CONTINUED HM021013CN002/P00044 | PAGE | OF |
4 | 4 |
NAME OF OFFEROR OR CONTRACTOR
DIGITALGLOBE, INC.
ITEM NO. (A) | SUPPLIES/SERVICES (B) | QUANTITY (C) | UNIT (D) | UNIT PRICE (E) | AMOUNT (F) |
[**REDACTED**] Funded: [**REDACTED**] Accounting Info: [**REDACTED**] Funded: [**REDACTED**] Period of Performance: 09/01/2016 to 08/31/2017 | |||||
G-1 Accounting and Appropriation Data | |||||
[**REDACTED**] [**REDACTED**] [**REDACTED**] [**REDACTED**] [**REDACTED**] [**REDACTED**] [**REDACTED**] [**REDACTED**] [**REDACTED**] [**REDACTED**] [**REDACTED**] [**REDACTED**] [**REDACTED**] [**REDACTED**] [**REDACTED**] [**REDACTED**] Total: | Amount [**REDACTED**] [**REDACTED**] [**REDACTED**] | ||||
NSN 7540-01-152-8067 | OPTIONAL FORM 336 (4-86) |
| Sponsored by GSA |
UNCLASSIFIED
HM0210-13-C-N002-P00044
UNCLASSIFIED//FOR OFFICIAL USE ONLY
WHEN SEPARATED FROM ATTACHMENT 1
This Table is UNCLASSIFIED | |||
CLIN | Maximum Total Price | Obligated Amount | Unfunded Amount |
CLIN Series 0400 |
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0401 | $300,000,000.00 | [**REDACTED**] | [**REDACTED**] |
0402 | [**REDACTED**] | [**REDACTED**] | [**REDACTED**] |
0403 | [**REDACTED**] | [**REDACTED**] | [**REDACTED**] |
0404 | [**REDACTED**] | [**REDACTED**] | [**REDACTED**] |
0405 | [**REDACTED**] | [**REDACTED**] | [**REDACTED**] |
0406 | [**REDACTED**] | [**REDACTED**] | [**REDACTED**] |
[**REDACTED**] | [**REDACTED**] | [**REDACTED**] | [**REDACTED**] |
0408 | [**REDACTED**] | [**REDACTED**] | [**REDACTED**] |
Subtotal Contract Year 5 | [**REDACTED**] | [**REDACTED**] | [**REDACTED**] |
CLIN Series 0500 | |||
0501 | $300,000,000.00 | [**REDACTED**] | [**REDACTED**] |
0502 | [**REDACTED**] | [**REDACTED**] | [**REDACTED**] |
0503 | [**REDACTED**] | [**REDACTED**] | [**REDACTED**] |
0504 | [**REDACTED**] | [**REDACTED**] | [**REDACTED**] |
0505 | [**REDACTED**] | [**REDACTED**] | [**REDACTED**] |
0506 | [**REDACTED**] | [**REDACTED**] | [**REDACTED**] |
[**REDACTED**] | [**REDACTED**] | [**REDACTED**] | [**REDACTED**] |
0508 | [**REDACTED**] | [**REDACTED**] | [**REDACTED**] |
0509 | [**REDACTED**] | [**REDACTED**] | [**REDACTED**] |
Subtotal Contract Year 6 | [**REDACTED**] | [**REDACTED**] | [**REDACTED**] |
CLIN Series 0600 | |||
0601 | $300,000,000.00 | [**REDACTED**] | [**REDACTED**] |
0602 | [**REDACTED**] | [**REDACTED**] | [**REDACTED**] |
0603 | [**REDACTED**] | [**REDACTED**] | [**REDACTED**] |
0604 | [**REDACTED**] | [**REDACTED**] | [**REDACTED**] |
0605 | [**REDACTED**] | [**REDACTED**] | [**REDACTED**] |
0606 | [**REDACTED**] | [**REDACTED**] | [**REDACTED**] |
[**REDACTED**] | [**REDACTED**] | [**REDACTED**] | [**REDACTED**] |
0608 | [**REDACTED**] | [**REDACTED**] | [**REDACTED**] |
0609 | [**REDACTED**] | [**REDACTED**] | [**REDACTED**] |
Subtotal Contract Year 7 | [**REDACTED**] | [**REDACTED**] | [**REDACTED**] |
CLIN Series 0700 | |||
0701 | $300,000,000.00 | [**REDACTED**] | [**REDACTED**] |
0702 | [**REDACTED**] | [**REDACTED**] | [**REDACTED**] |
0703 | [**REDACTED**] | [**REDACTED**] | [**REDACTED**] |
0704 | [**REDACTED**] | [**REDACTED**] | [**REDACTED**] |
0705 | [**REDACTED**] | [**REDACTED**] | [**REDACTED**] |
0706 | [**REDACTED**] | [**REDACTED**] | [**REDACTED**] |
[**REDACTED**] | [**REDACTED**] | [**REDACTED**] | [**REDACTED**] |
Subtotal Contract Year 8 | [**REDACTED**] | [**REDACTED**] | [**REDACTED**] |
CLIN Series 0800 | |||
0801 | $300,000,000.00 | [**REDACTED**] | [**REDACTED**] |
0802 | [**REDACTED**] | [**REDACTED**] | [**REDACTED**] |
0803 | [**REDACTED**] | [**REDACTED**] | [**REDACTED**] |
0804 | [**REDACTED**] | [**REDACTED**] | [**REDACTED**] |
0805 | [**REDACTED**] | [**REDACTED**] | [**REDACTED**] |
Contract Page 22 of 64
UNCLASSIFIED//FOR OFFICIAL USE ONLY
WHEN SEPARATED FROM ATTACHMENT 1
HM0210-13-C-N002-P00044
UNCLASSIFIED//FOR OFFICIAL USE ONLY
WHEN SEPARATED FROM ATTACHMENT 1
This Table is UNCLASSIFIED | |||
CLIN | Maximum Total Price | Obligated Amount | Unfunded Amount |
0806 | [**REDACTED**] | [**REDACTED**] | [**REDACTED**] |
[**REDACTED**] | [**REDACTED**] | [**REDACTED**] | [**REDACTED**] |
Subtotal Contract Year 9 | [**REDACTED**] | [**REDACTED**] | [**REDACTED**] |
CLIN Series 0900 |
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0901 | $300,000,000.00 | [**REDACTED**] | [**REDACTED**] |
0902 | [**REDACTED**] | [**REDACTED**] | [**REDACTED**] |
0903 | [**REDACTED**] | [**REDACTED**] | [**REDACTED**] |
0904 | [**REDACTED**] | [**REDACTED**] | [**REDACTED**] |
0905 | [**REDACTED**] | [**REDACTED**] | [**REDACTED**] |
0906 | [**REDACTED**] | [**REDACTED**] | [**REDACTED**] |
[**REDACTED**] | [**REDACTED**] | [**REDACTED**] | [**REDACTED**] |
Subtotal Contract Year 10 | [**REDACTED**] | [**REDACTED**] | [**REDACTED**] |
Total Contract Value with Options | $2,587,780,000.00 | [**REDACTED**] | [**REDACTED**] |
B.8 (U) CLIN DESCRIPTION
(U) In accordance with this contract, the Contractor shall furnish all materials, labor, equipment and facilities, except as specified herein to be furnished by the Government, and shall do all that which is necessary or incidental to the satisfactory and timely performance of CLINs 0301 through 0306 (and Option CLINs if exercised) as stated below.
B.9 (U) CONTRACT TYPE
(U) This is a hybrid Firm Fixed Price (FFP) and Time and Material contract (predominately FFP), with base and option periods as specified in Section/Paragraph F.5.
(U) OPTION PERIODS
B.10 (U) (U) OPTION CLINs 0301, 0401, 0501, 0601, 0701, 0801 and 0901 – COMMERCIAL SATELLITE IMAGERY - SERVICE LEVEL AGREEMENT (SLA) OR SATELLITE ACCESS AGREEEMENT (SAA) FOR PIXEL & IMAGERY ACQUISITION/OPERATIONS (BASELINE COLLECTION CAPACITY)
(U) The scope of this FFP CLIN Series for the acquisition and delivery of imagery and associated imagery support data from the Contractor’s satellite constellation is defined in Contract Attachment 1, EnhancedView Imagery Acquisition Statement of Work [**REDACTED**], and in accordance with Special Contract Requirement H.24, Exercise of Options. This effort is priced at the amounts set forth below.
This Table is UNCLASSIFIED | |||
Options: Contract Years 2 through 10 | |||
CLIN Series 0x01 | Baseline Quantity | Firm Fixed Price | |
Option CLIN 0101 (Contract Year 2) | [**REDACTED**] (reference HM0210-10-C-0002) | ||
Option CLIN 0201 (Contract Year 3) | [**REDACTED**] (reference HM0210-10-C-0002) | ||
Option CLIN 0301 (Contract Year 4) | [**REDACTED**] | $ 250,000,000.00 | |
[**REDACTED**] | Option CLIN 0401 (Contract Year 5) * | [**REDACTED**] | $ 300,000,000.00 |
Option CLIN 0501 (Contract Year 6) * | [**REDACTED**] | $ 300,000,000.00 | |
Option CLIN 0601 (Contract Year 7) * | [**REDACTED**] | $ 300,000,000.00 | |
Option CLIN 0701 (Contract Year 8) * | [**REDACTED**] | $ 300,000,000.00 | |
Option CLIN 0801 (Contract Year 9) * | [**REDACTED**] | $ 300,000,000.00 | |
Option CLIN 0901 (Contract Year 10) * | [**REDACTED**] | $ 300,000,000.00 |
Contract Page 23 of 64
UNCLASSIFIED//FOR OFFICIAL USE ONLY
WHEN SEPARATED FROM ATTACHMENT 1
HM0210-13-C-N002-P00044
UNCLASSIFIED//FOR OFFICIAL USE ONLY
WHEN SEPARATED FROM ATTACHMENT 1
This Table is UNCLASSIFIED | |||||
Action | CLIN | ACRN | Fund Cite | Obligated | Cumulative |
[**REDACTED**] | [**REDACTED**] | [**REDACTED**] | [**REDACTED**] | [**REDACTED**] | [**REDACTED**] |
|
| Total | [**REDACTED**] | ||
[**REDACTED**] | [**REDACTED**] | [**REDACTED**] | [**REDACTED**] | [**REDACTED**] | [**REDACTED**] |
|
| Total | [**REDACTED**] | ||
[**REDACTED**] | [**REDACTED**] | [**REDACTED**] | [**REDACTED**] | [**REDACTED**] | [**REDACTED**] |
[**REDACTED**] | [**REDACTED**] | [**REDACTED**] | [**REDACTED**] | ||
|
| Total | [**REDACTED**] | ||
[**REDACTED**] | [**REDACTED**] | [**REDACTED**] | [**REDACTED**] | [**REDACTED**] | [**REDACTED**] |
[**REDACTED**] | [**REDACTED**] | [**REDACTED**] | [**REDACTED**] | ||
[**REDACTED**] | [**REDACTED**] | [**REDACTED**] | [**REDACTED**] | ||
[**REDACTED**] | [**REDACTED**] | [**REDACTED**] | [**REDACTED**] | ||
|
| Total | [**REDACTED**] | ||
[**REDACTED**] | [**REDACTED**] | [**REDACTED**] | [**REDACTED**] | [**REDACTED**] | [**REDACTED**] |
[**REDACTED**] | [**REDACTED**] | [**REDACTED**] | [**REDACTED**] | ||
[**REDACTED**] | [**REDACTED**] | [**REDACTED**] | [**REDACTED**] | ||
[**REDACTED**] | [**REDACTED**] | [**REDACTED**] | [**REDACTED**] | ||
[**REDACTED**] | [**REDACTED**] | [**REDACTED**] | [**REDACTED**] | ||
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| [**REDACTED**] | ||
[**REDACTED**] | [**REDACTED**] | [**REDACTED**] | [**REDACTED**] | [**REDACTED**] | [**REDACTED**] |
[**REDACTED**] | [**REDACTED**] | [**REDACTED**] | [**REDACTED**] | ||
|
| Total | [**REDACTED**] | ||
[**REDACTED**] | [**REDACTED**] | [**REDACTED**] | [**REDACTED**] | [**REDACTED**] | [**REDACTED**] |
[**REDACTED**] | [**REDACTED**] | [**REDACTED**] | [**REDACTED**] | ||
[**REDACTED**] | [**REDACTED**] | [**REDACTED**] | [**REDACTED**] | ||
[**REDACTED**] | [**REDACTED**] | [**REDACTED**] | [**REDACTED**] | ||
|
| Total | [**REDACTED**] | ||
[**REDACTED**] | [**REDACTED**] | [**REDACTED**] | [**REDACTED**] | [**REDACTED**] | [**REDACTED**] |
[**REDACTED**] | [**REDACTED**] | [**REDACTED**] | [**REDACTED**] | ||
[**REDACTED**] | [**REDACTED**] | [**REDACTED**] | [**REDACTED**] | ||
|
| Total | [**REDACTED**] | ||
[**REDACTED**] | [**REDACTED**] | [**REDACTED**] | [**REDACTED**] | [**REDACTED**] | [**REDACTED**] |
[**REDACTED**] | [**REDACTED**] | [**REDACTED**] | [**REDACTED**] | ||
|
| Total | [**REDACTED**] | ||
[**REDACTED**] | [**REDACTED**] | [**REDACTED**] | [**REDACTED**] | [**REDACTED**] | [**REDACTED**] |
[**REDACTED**] | [**REDACTED**] | [**REDACTED**] | [**REDACTED**] | ||
|
| Total | [**REDACTED**] | ||
[**REDACTED**] | [**REDACTED**] | [**REDACTED**] | [**REDACTED**] | [**REDACTED**] | [**REDACTED**] |
[**REDACTED**] | [**REDACTED**] | [**REDACTED**] | [**REDACTED**] | ||
|
| Total | [**REDACTED**] | ||
[**REDACTED**] | [**REDACTED**] | [**REDACTED**] | [**REDACTED**] | [**REDACTED**] | [**REDACTED**] |
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| Total | [**REDACTED**] | ||
[**REDACTED**] | [**REDACTED**] | [**REDACTED**] | [**REDACTED**] | [**REDACTED**] | [**REDACTED**] |
[**REDACTED**] | [**REDACTED**] | [**REDACTED**] | [**REDACTED**] | ||
|
| Total | [**REDACTED**] | ||
[**REDACTED**] | [**REDACTED**] | [**REDACTED**] | [**REDACTED**] | [**REDACTED**] | [**REDACTED**] |
[**REDACTED**] | [**REDACTED**] | [**REDACTED**] | [**REDACTED**] | ||
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| Total | [**REDACTED**] | ||
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Contract Page 34a of 64
UNCLASSIFIED//FOR OFFICIAL USE ONLY
WHEN SEPARATED FROM ATTACHMENT 1