CIA-RDP96-00792R000100140026-4

ApprovesFRACT PRICING PROPOSAL
(RESEARCH AND DEVELOPMENT)
ase. 2003759/10 ; CIA-RDP96-00792R00010014002624proved
This form is for use when (i) submission of cost or pricing duta (see ASPR 3-807.3) is
required and (ii) substitution for the DD Form 633 is authorized by the contracting officer.
PAGE NO.
1
NO. OF PAGES
2
NAME OF OFFEROR
SRI International
SUPPLIES AND/OR SERVICES TO BE FURNISHED
Research
HOME OFFICE ADDRESS (Include ZIP Code)
333 Ravenswood Avenue
Menlo Park, California 94025
DIVISION(S) AND LOCATION(S) WHERE WORK IS TO BE PERFORMED
As above
TOTAL AMOUNT OF PROPOSAL
$ 74,986
GOVT SOLICITATION NO.
-
-
DETAIL DESCRIPTION OF COST ELEMENTS
1. DIRECT MATERIAL (Itemize on Exhibit A)
EST COST ($)
TOTAL
EST COSTI
REFER- 2.
ENCE
a. PURCHASED PARTS
b. SUBCONTRACTED ITEMS
c. OTHER - (1) RAW MATERIAL
(2) YOUR STANDARD COMMERCIAL ITEMS
(3) INTERDIVISIONAL TRANSFERS (At other than coat)
TOTAL DIRECT MATERIAL
2. MATERIAL OVERHEAD 3 (Rate
% X $ base = )
3. DIRECT LABOR (Specify)
ESTIMATED
HOURS
RATE/
HOUR
EST
COST ($)
TOTAL DIRECT LABOR
4. LABOR OVERHEAD (Specify department or cost center) 3
O.H. RATE
X BASE =
EST COST ($)
TOTAL LABOR OVERHEAD
5. SPECIAL TESTING (Including field work at Government installations)
EST COST ($)
TOTAL SPECIAL TESTING
6. SPECIAL EQUIPMENT (If direct charge) (Itemize on Exhibit A)
7. TRAVEL (If direct charge) (Give details on attached Schedule)
a. TRANSPORTATION
b. PER DIEM OR SUBSISTENCE
TOTAL TRAVEL
8. CONSULTANTS (Identity - purpose - rate)
EST COST ($)
TOTAL CONSULTANTS
9. OTHER DIRECT COSTS (Itemize on Exhibit A)
10.
TOTAL DIRECT COST AND OVERHEAD
12. ROYALTIES 4
13.
TOTAL ESTIMATED COST
See Part Two -- Contractual
14. FEE OR PROFIT
Provisions No. ESU 78-100
15.
TOTAL ESTIMATED COST AND FEE OR PROFIT
This proposal is submitted for use in connection with and in response to (Describe RFP, etc.,
and reflects our best estimates as of this date, in accordance with the instructions to offerors and the footnotes which follow.
TYPED NAME AND TITLE
Phillp J. O'Donnell'
Manager
Contract Administration
SIGNATURE
NAME OF FIRM
SRI International
DATE OF SUBMISSION
1978 SEP 28
DD , APR 68
633-4
FORM
REPLACES EDITION OF 1 JAN 67, WHICH IS OBSOLETE.
Approved For Release 2003/09/10 : CIA-RDP96-00792R000100140026-4
Budget Bureau No. 22-R0100
11. GENERAL AND ADMINISTRATIVE EXPENSE (Rate
% of cost element Nos.
) 3
EST COST ($)

COST EL NO.
ITEM DESCRIPTION (See footnote 5)
EST COST ($)
HAVE THE DEPARTMENT OF DEFENSE, NATIONAL AERONAUTICS AND SPACE ADMINISTRATION, OR THE ATOMIC ENERGY COM-
MISSION PERFORMED ANY REVIEW OF YOUR ACCOUNTS OR RECORDS IN CONNECTION WITH ANY OTHER GOVERNMENT PRIME
CONTRACT OR SUBCONTRACT WITHIN THE PAST TWELVE MONTHS?
YES
NO If yes, identity below.
NAME AND ADDRESS OF REVIEWING OFFICE
(Include ZIP Code)
Defense Contract Audit Agency, SRI Resident
TELEPHONE NUMBER/EXTENSION
415 326-6200, X2089
I. WILL YOU REQUIRE THE USE OF ANY GOVERNMENT PROPERTY IN THE PERFORMANCE OF THIS PROPOSED CONTRACT?
YES
NO If yes, identify on a separate page.
III. DO YOU REQUIRE GOVERNMENT CONTRACT FINANCING TO PERFORM THIS PROPOSED CONTRACT?
YES
NO
if yes, identify :
ADVANCE PAYMENTS
PROGRESS PAYMENTS OR
GUARANTEED LOANS
IV. DO YOU NOW HOLD ANY CONTRACT (or, do you have any independently financed (IR & D) projects) FOR THE SAME OR SIMILAR WORK
CALLED FOR BY THIS PROPOSED CONTRACT?
YES
NO If yes, identify
V. DOES THIS COST SUMMARY CONFORM WITH THE COST PRINCIPLES SET FORTH IN ASPR, SECTION XV (See 3-807.2 (c) (2))?
YES
NO If no, explain on a separate page.
INSTRUCTIONS TO OFFERORS
1. The purpose of this form is to provide a standard format by
which the offeror submits to the Government a summary of in-
curred and estimated cost (and attached supporting information)
suitable for detailed review and analysis. Prior to the award
of a contract resulting from this proposal the offeror shall,
under the conditions stated in ASPR 3-807.3, be required to
submit a Certificate of Current Cost or Pricing Data (see ASPR
3-807.3(e) and 3-807.4).
2. As part of the specific information required by this form, the
offeror must submit with this form, and clearly identify as such,
cost or pricing data (that is, data which is verifiable and fac-
tual and otherwise as defined in ASPR 3-807.3(e)). In addition,
he must submit with this form any information reasonably requir -
ed to explain the offeror's estimating process, including:
a. the judgmental factors applied and the mathematical
or other methods used in the estimate including those
used in projecting from known data, and
b. the contingencies used by offeror in his proposed
price.
3. When attachment of supporting cost of pricing data to this
form is impracticable, the data will be specifically identified
and described (with schedules as appropriate), and made
available to the contracting officer or his representative upon
request.
4. The format for the "Cost Elements" is not intended as
rigid requirements. These may be presented in different
format with the prior approval of the contracting officer if
required for more effective and efficient presentation. In all
other respects this form will be completed and submitted
without change.
5. By submission of this proposal offeror, if selected for
negotiation, grants to the contracting officer, or his author-
ized representative, the right to examine, for the purpose of
verifying the cost or pricing data submitted, those books,
records, documents and other supporting data which will
permit adequate evaluation of such cost or pricing data, along
with the computations and projections used therein. This
right may be exercised in connection with any negotiations
prior to contract award.
FOOTNOTES
1
Enter in this column those necessary and reasonable costs
which in the judgment of the offeror will properly be incurred
in the efficient performance of the contract. When any of the
costs in this column have already been incurred (e.g., on a
letter contract or change order), describe them on an attached
supporting schedule. Identify all sales and transfers between
your plants, divisions, or organizations under a common con-
trol, which are included at other than the lower of cost to the
original transferror or current market price.
2
When space in addition to that available in Exhibit A is
required, attach separate pages as necessary and identify in
this "Reference" column the attachment in which information
supporting the specific cost element may be found. No stand-
ard format is prescribed; however, the cost or pricing data must
be accurate, complete and current, and the judgment factors
used in projecting from the data to the estimates must be stated
in sufficient detail to enable the contracting officer to evaluate
the proposal. For example, provide the basis used for pricing
materials such as by vendor quotations, shop estimates, or
invoice prices; the reason for use of overhead rates which de-
part significantly from experienced rates (reduced volume, a
planned major rearrangement, etc.): or justification for an in-
crease in labor rates (anticipated wage and salary increases,
etc.). Identify and explain any contingencies which are included
in the proposed price, such as anticipated costs of rejects and
defective work, or anticipated technical difficulties.
-
3 Indicate the rates used and provide an appropriate explana-
tión. Where agreement has been reached with Government rep-
resentatives on the use of forward pricing rates, describe the
nature of the agreement. Provide the method of computation
and application of your overhead expense, including cost
breakdown and showing trends and budgetary data as neces-
sary to provide a basis for evaluation of the reasonableness
of proposed rates.
4 If the total royalty cost entered here is in excess of $250
provide on a separate page (or on DD Form 783, Royalty
Report) the following information on each separate item of
royalty or license fee: name and address of licensor; date of
license agreement; patent numbers, patent application serial
numbers, or other basis on which the royalty is payable; brief
description, including any part or model numbers of each con-
tract item or component on which the royalty is payable; per-
centage or dollar rate of royalty per unit; unit price of contract
item; number of units; and total dollar amount of royalties.
In addition, if specifically requested by the contracting officet
a copy of the current license agreement and identification of
applicable claims of specific patents shall be provided.
5 Provide a list of principal items within each category in-
dicating known or anticipated source, quantity, unit price,
competition obtained, and basis of establishing source and
reasonableness of cost.
Approved For Release 2003/09/10 : CIA-RDP96-00792R000100140026-4

Approved ForRelease.2003/09/10 : CIA-RDP96-00792R000100140026-4
CONTRACT PRICING PROPOSAL
(RESEARCH AND DEVELOPMENT)
Form Approved
Budget Bureau No. 22-R0100
This form is for use when (i) submission of cost or pricing data (see ASPR 3-807.3) is
required and (il) substitution for the DD Form 633 is authorized by the contracting officer.
PAGE NO.
1
NO. OF PAGES
2
NAME OF OFFEROR
SRI International
SUPPLIES AND/OR SERVICES TO BE FURNISHED
Research
HOME OFFICE ADDRESS (Include ZIP Code)
333 Ravenswood Avenue
Menlo Park, California
94025
DIVISION(S) AND LOCATION(S) WHERE WORK IS TO BE PERFORMED
As above
TOTAL AMOUNT OF PROPOSAL
$ 74,986
GOVT SOLICITATION NO.
- - -
DETAIL DESCRIPTION OF COST ELEMENTS
1. DIRECT MATERIAL (Itemize on Exhibit A)
EST COST ($)
TOTAL
EST COSTI
REFER- 2
ENCE
a. PURCHASED PARTS
b. SUBCONTRACTED ITEMS
c. OTHER - (1) RAW MATERIAL
(2) YOUR STANDARD COMMERCIAL ITEMS
(3) INTERDIVISIONAL TRANSFERS (At other than cost)
TOTAL DIRECT MATERIAL .
2. MATERIAL OVERHEAD 3
(Rate
% X $ base = )
3. DIRECT LABOR (Specify)
ESTIMATED
HOURS
RATE/
HOUR
EST
COST ($)
TOTAL DIRECT LABOR
4. LABOR OVERHEAD (Specify department or cost center) 3
O.H. RATE
X BASE =
EST COST ($)
TOTAL LABOR OVERHEAD
5. SPECIAL TESTING (Including field work at Government installations)
EST COST ($)
TOTAL SPECIAL TESTING
6., SPECIAL EQUIPMENT (If direct charge) (Itemize on Exhibit A)
7. TRAVEL (If direct charge) (Give details on attached Schedule)
a. TRANSPORTATION
b. PER DIEM OR SUBSISTENCE
TOTAL TRAVEL
8. CONSULTANTS (Identity - purpose - rate)
EST COST ($)
TOTAL CONSULTANTS
9. OTHER DIRECT COSTS (Itemize on Exhibit A)
10.
TOTAL DIRECT COST AND OVERHEAD
11. GENERAL AND ADMINISTRATIVE EXPENSE (Rate
% of cost element Nos.
) 3
12. ROYALTIES 4
13.
TOTAL ESTIMATED COST
See Part Two+-Contractual
15.
TOTAL ESTIMATED COST AND FEE OR PROFIT
This proposal is submitted for use in connection with and in response to (Describe RFP, etc.,
-
and reflects our best estimates as of this date, in accordance with the instructions to offerors and the footnotes which follow.
TYPED NAME AND TITLE
Philip J. O'Donnell'
Manager
Contract Administration
SIGNATURE
Thin 9000000
NAME OF FIRM
SRI International
DATE OF SUBMISSION
1978 SEP 28
DD , APR 68
633-4
FORM
REPLACES EDITION OF 1 JAN 67, WHICH IS OBSOLETE.
Approved For Release 2003/09/10 : CIA-RDP96-00792R000100140026-4
EST COST ($)
14. FEE OR PROFIT
Provisions No. ESU 78-100

EXATOvedUPSPRUNG <<< 2008/09/10GAARDP9600792R0001001400264)
COST EL NO.
ITEM DESCRIPTION (See footnote .5)
EST COST ($)
.
1.
HAVE THE DEPARTMENT OF DEFENSE, NATIONAL AERONAUTICS AND SPACE ADMINISTRATION, OR THE ATOMIC ENERGY COM-
MISSION PERFORMED ANY REVIEW OF YOUR ACCOUNTS OR RECORDS IN CONNECTION WITH ANY OTHER GOVERNMENT PRIME
CONTRACT OR SUBCONTRACT WITHIN THE PAST TWELVE MONTHS?
YES
NO If yes, identify below.
NAME AND ADDRESS OF REVIEWING OFFICE
Defense Contract Audit Agency, SRI Resident
(Include ZIP Code)
TELEPHONE NUMBER/EXTENSION
415 326-6200, X2089
1. WILL YOU REQUIRE THE USE OF ANY GOVERNMENT PROPERTY IN THE PERFORMANCE OF THIS PROPOSED CONTRACT?
YES
NO If yes, identify on a separate page.
III. DO YOU REQUIRE GOVERNMENT CONTRACT FINANCING TO PERFORM THIS PROPOSED CONTRACT?
YES
NO if yes, identify :,
ADVANCE PAYMENTS
PROGRESS PAYMENTS OR
GUARANTEED LOANS
IV. DO YOU NOW HOLD ANY CONTRACT (ot, do you have any independently financed (IR & D) projects) FOR THE SAME OR SIMILAR WORK
CALLED FOR BY THIS PROPOSED CONTRACT?
YES
NO If yes, identify
V. DOES THIS COST SUMMARY CONFORM WITH THE COST PRINCIPLES SET FORTH IN ASPR, SECTION XV (See 3-807.2 (c) (2)?
YES
NO
If no, explain on a separate page.
INSTRUCTIONS TO OFFERORS
1. The purpose of this form is to provide a standard format by
which the offeror submits to the Government a summary of in-
curred and estimated cost (and attached supporting information)
suitable for detailed review and analysis. Prior to the award
of a contract resulting from this proposal the offeror shall,
under the conditions stated in ASPR 3-807.3, be required to
submit a Certificate of Current Cost or Pricing Data (see ASPR
3-807.3(e) and 3-807.4).
2. As part of the specific information required by this form, the
offeror must submit with this form, and clearly identify as such,
cost or pricing data (that is, data which is verifiable and fac-
tual and otherwise as defined in ASPR 3-807.3(e)). In addition,
he must submit with this form any information reasonably requir -
ed to explain the offeror's estimating process, including:
a. the judgmental factors applied and the mathematical
or other methods used in the estimate including those
used in projecting from known data, and
b. the contingencies used by offeror in his proposed
price.
3. When attachment of supporting cost or pricing data to this
form is impracticable, the data will be specifically identified
and described (with schedules as appropriate), and made
available to the contracting officer or his representative upon
request.
4. The format for the "Cost Elements" is not intended as
rigid requirements. These may be presented in different
format with the prior approval of the contracting officer if
required for more effective and efficient presentation. In all
other respects this form will be completed and submitted
without change.
5. By submission of this proposal offeror, if selected for
negotiation, grants to the contracting officer, or his author-
ized representative, the right to examine, for the purpose of
verifying the cost or pricing data submitted, those books,
records, documents and other supporting data which will
permit adequate evaluation of such cost or pricing data, along
with the computations and projections used therein. This
right may be exercised in connection with any negotiations
prior to contract award.
FOOTNOTES
1
Enter in this column those necessary and reasonable costs
which in the judgment of the offeror will properly be incurred
in the efficient performance of the contract. When any of the
costs in this column have already been incurred (e.g., on a
letter contract or change order), describe them on an attached
supporting schedule. Identify all sales and transfers between
your plants, divisions, or organizations under a common con-
trol, which are included at other than the lower of cost to the
original transferror or current market price.
2
When space in addition to that available in Exhibit A is
required, attach separate pages as necessary and identify in
this "Reference" column the attachment in which information
supporting the specific cost element may be found. No stand-
ard format is prescribed; however, the cost or pricing data must
be accurate, complete and current, and the judgment factors
used in projecting from the data to the estimates must be stated
in sufficient detail to enable the contracting officer to evaluate
the proposal. For example, provide the basis used for pricing
materials such as by vendor quotations, shop estimates, or
invoice prices; the reason for use of overhead rates which de-
part significantly from experienced rates (reduced volume, a
planned major rearrangement, etc.): or justification for an in-
crease in labor rates (anticipated wage and salary increases,
etc.). Identify and explain any contingencies which are included
in the proposed price, such as anticipated costs of rejects and
defective work, or anticipated technical difficulties.
3 Indicate the rates used and provide an appropriate explana-
tion. Where agreement has been reached with Government rep-
resentatives on the use of forward pricing rates, describe the
nature of the agreement. Provide the method of computation
and application of your overhead expense, including cost
breakdown and showing trends and budgetary data as neces-
sary to provide a basis for evaluation of the reasonableness
of proposed rates.
4 If the total royalty cost entered here is in excess of $250
provide on a separate page (or on DD Form 783, Royalty
Report) the following information on each separate item of
royalty or license fee: name and address of licensor; date of
license agreement; patent numbers, patent application serial
numbers, or other basis on which the royalty is payable; brief
description, including any part or model numbers of each con-
tract item or component on which the royalty is payable; per-
centage or dollar rate of royalty per unit; unit price of contract
item; number of units; and total dollar amount of royalties.
In addition, if specifically requested by the contracting officer,
a copy of the current license agreement and identification of
applicable claims of specific patents shall be provided.
5
Provide a list of principal items within each category in-
dicating known or anticipated source, quantity, unit price,
competition obtained, and basis of establishing source and
reason ableness of cost.
Approved For Release 2003/09/10 : CIA-RDP96-00792R000100140026-4

COST EL NO.
ITEM DESCRIPTION (See footnote 5)
EST COST ($)
1.
HAVE THE DEPARTMENT OF DEFENSE, NATIONAL AERONAUTICS AND SPACE ADMINISTRATION, OR THE ATOMIC ENERGY COM-
MISSION PERFORMED ANY REVIEW OF YOUR ACCOUNTS OR RECORDS IN CONNECTION WITH ANY OTHER GOVERNMENT PRIME
CONTRACT OR SUBCONTRACT WITHIN THE PAST TWELVE MONTHS?
YES
NO If yes, identity below.
NAME AND ADDRESS OF REVIEWING OFFICE
(Include ZIP Code)
Defense Contract Audit Agency, SRI Resident
TELEPHONE NUMBER/EXTENSION
415 326-6200, X2089
11. WILL YOU REQUIRE THE USE OF ANY GOVERNMENT PROPERTY IN THE PERFORMANCE OF THIS PROPOSED CONTRACT?
YES
NO If yes, identify on a separate page.
III. DO YOU REQUIRE GOVERNMENT CONTRACT FINANCING TO PERFORM THIS PROPOSED CONTRACT?
YES
NO
if yes, identify :
ADVANCE PAYMENTS
] PROGRESS PAYMENTS OR
GUARANTEED LOANS
IV. DO YOU NOW HOLD ANY CONTRACT (or, do you have any independently financed (IR & D) projects) FOR THE SAME OR SIMILAR WORK
CALLED FOR BY THIS PROPOSED CONTRACT?
YES
NO If yes, identify
V. DOES THIS COST SUMMARY CONFORM WITH THE COST PRINCIPLES SET FORTH IN ASPR, SECTION XV (See 3-807.2 (c) (2))?
YES
NO If no, explain on a separate page.
INSTRUCTIONS TO OFFERORS
1. The purpose of this form is to provide a standard format by
which the offeror submits to the Government a summary of in-
curred and estimated cost (and attached supporting information)
suitable for detailed review and analysis. Prior to the award
of a contract resulting from this proposal the offeror shall,
under the conditions stated in ASPR 3-807.3, be required to
submit a Certificate of Current Cost or Pricing Data (see ASPR
3-807.3(e) and 3-807.4).
2. As part of the specific information required by this form, the
offeror must submit with this form, and clearly identify as such,
cost or pricing data (that is, data which is verifiable and fac-
tual and otherwise as defined in ASPR 3-807.3(e)). In addition,
he must submit with this form any information reasonably requir -
ed to explain the offeror's estimating process, including:
a. the judgmental factors applied and the mathematical
or other methods used in the estimate including those
used in projecting from known data, and
b. the contingencies used by offeror in his proposed
price.
3. When attachment of supporting cost or pricing data to this
form is impracticable, the data will be specifically identified
and described (with schedules as appropriate), and made
available to the contracting officer or his representative upon
request.
4. The format for the "Cost Elements" is not intended as
rigid requirements. These may be presented in different
format with the prior approval of the contracting officer if
required for more effective and efficient presentation. In all
other respects this form will be completed and submitted
without change.
5. By submission of this proposal offeror, if selected for
negotiation, grants to the contracting officer, or his author-
ized representative, the right to examine, for the purpose of
verifying the cost or pricing data submitted, those books,
records, documents and other supporting data which will
permit adequate evaluation of such cost or pricing data, along
with the computations and projections used therein. This
right may be exercised in connection with any negotiations
prior to contract award.
FOOTNOTES
-
Enter in this column those necessary and reasonable costs
which in the judgment of the offeror will properly be incurred
in the efficient performance of the contract. When any of the
costs in this column have already been incurred (e.g., on a
letter contract or change order), describe them on an attached
supporting schedule. Identify all sales and transfers between
your plants, divisions, or organizations under a common con-
trol, which are included at other than the lower of cost to the
original transferror or current market price.
2
When space in addition to that available in Exhibit A is
required, attach separate pages as necessary and identify in
this "Reference" column the attachment in which information
supporting the specific cost element may be found. No stand-
ard format is prescribed; however, the cost or pricing data must
be accurate, complete and current, and the judgment factors
used in projecting from the data to the estimates must be stated
in sufficient detail to enable the contracting officer to evaluate
the proposal. For example, provide the basis used for pricing
materials such as by vendor quotations, shop estimates, or
invoice prices; the reason for use of overhead rates which de-
part significantly from experienced rates (reduced volume, a
planned major rearrangement, etc.): or justification for an in-
crease in labor rates (anticipated wage and salary increases,
etc.). Identify and explain any contingencies which are included
in the proposed price, such as anticipated costs of rejects and
defective work, or anticipated technical difficulties.
3 Indicate the rates used and provide an appropriate explana-
tión. Where agreement has been reached with Government rep-
resentatives on the use of forward pricing rates, describe the
nature of the agreement. Provide the method of computation
and application of your overhead expense, including cost
breakdown and showing trends and budgetary data as neces-
sary to provide a basis for evaluation of the reasonableness
of proposed rates.
4. If the total royalty cost entered here is in excess of $250
provide on a separate page (or on DD Form 783, Royalty
Report) the following information on each separate item of
royalty or license fee: name and address of licensor; date of
license agreement; patent numbers, patent application serial
numbers, or other basis on which the royalty is payable; brief
description, including any part or model numbers of each con-
tract item or component on which the royalty is payable; per
centage or dollar rate of royalty per unit; unit price of contract
item; number of units; and total dollar amount of royalties.
In addition, if specifically requested by the contracting officet
a copy of the current license agreement and identification of
applicable claims of specific patents shall be provided.
5 Provide a list of principal items within each category in-
dicating known or anticipated source, quantity, unit price,
competition obtained, and basis of establishing source and
reasonableness of cost.
Approved For Release 2003/09/10 : CIA-RDP96-00792R000100140026-4

#U.S. GOVERNMENT PRINTING OFFICE: 1974 -558 - 057
CLASSIFIED POLLINENOMATICCIONTABIRIPPRECU ADAR000100140926 4
DATE
2 Oct 78
For use of this form, see AR 380-5; the proponent agency is the Office, Assistant Chief of Staff for Intelligence.
SECTION A - GENERAL
TO:
FROM:
hand carried
DATE RECEIVED
ACTION OFFICE(S)
SUSPENSE DATE (S)
REGISTER OR CONTROL NO.
CONTROL, LOG
OR FILE NO.
CLASSIFI-
CATION
NUMBER OF
COPIES
DESCRIPTION (Type. File Ref., Unclassified Subject
or Short Title and Number of Indorsements/ Incls)
DATE OF
DOCUMENT
ORIGINATOR
S
1
letter, w/SRI Proposal No. ESU 78-100
(3 cys) DD Form 633-4 (3 cys)
-NOTHING FOLLOWS-
SECTION B - ROUTING
TO
COPY NO.
DATE
PRINTED NAME
SIGNATURE
1.
2.
3.
4.
5.
MATERIAL DESCRIBED HEREON HAS BEEN:
DESTROYED
TORN IN HALF AND PLACED IN A CLASSIFIED WASTE CONTAINER (AR 380-5)
OFFICE SYMBOL
DATE
PRINTED NAME OF CUSTODIAN OR REP
SIGNATURE
DESTRUCTION RECORD NO.
DATE
PRINTED NAME OF CERTIFYING/DESTR. OFF.
SIGNATURE
PAGE OR COPY NUMBER
DATE
PRINTED NAME OF WITNESSING OFFICIAL
SIGNATURE
SECTION D - REPRODUCTION AUTHORITY
NUMBER OF COPIES TO BE REPRODUCED
AUTHORIZED BY
DATE
SECTION E - RECEIPT/TRACER ACTION (Check appropriate block)
RECEIPT OF DOCUMENT(S) ACKNOWLEDGED
DOCUMENT(S) HAVE NOT BEEN RECEIVED
TRACER ACTION: SIGNED RECEIPT FOR MATERIAL DESCRIBED ABOVE HAS NOT BEEN RECEIVED.
DATE
PRINTED NAME, GRADE OR TITLE
SIGNATURE
COMMENTS
Approved For Release 2003/09/10 : CIA-RDP96-00792R000100140026-4
DA FORM 3964, 1 Nov 72
REPLACES DA FORMS 1203, 1 SEP 58: 1204. 1 JAN 60: 631, 1 MAR 62 AND
546, 1 OCT 63, WHICH ARE OBSO
OBSOLETE.
28Sep78
SRI
SECTION C - DESTRUCTION CERTIFICATE (Check appropriate block)
MAJ STONER, DAMI-ISH