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

What Is DD Form 441-1?

This is a form that was released by the U.S. Department of Defense (DoD) on March 1, 2020. The form, often mistakenly referred to as the DA Form 441-1, is a military form used by and within the U.S. Army. As of today, no separate instructions for the form are provided by the DoD.

Form Details:

  • A 1-page document available for download in PDF;
  • The latest version available from the Executive Services Directorate;
  • Editable, printable, and free to use;
  • Fill out the form in our online filing application.

Download an up-to-date fillable DD Form 441-1 down below in PDF format or browse hundreds of other DoD Forms compiled in our online library.

ADVERTISEMENT
ADVERTISEMENT

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

Download PDF

Fill PDF online

Rate (4.5 / 5) 265 votes
OMB No. 0704-0194
APPENDAGE TO DEPARTMENT OF DEFENSE SECURITY AGREEMENT
OMB approval expires
20201031
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 03F09, 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. DISCLOSURE: 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 Counterintelligence and Security Agency, 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
CITY AND STATE
CONTRACTOR (Typed Name)
THE UNITED STATES OF AMERICA
BY (Signature of Government Representative)
BY (Signature of Authorized Contractor Representative)
AUTHORIZED REPRESENTATIVE OF THE GOVERNMENT
TITLE (of Authorized Contractor Representative)
(Typed Name of Government Agency)
ADDRESS
DD FORM 441-1, MARCH 2020
RESET
PREVIOUS EDITION IS OBSOLETE.
OMB No. 0704-0194
APPENDAGE TO DEPARTMENT OF DEFENSE SECURITY AGREEMENT
OMB approval expires
20201031
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 03F09, 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. DISCLOSURE: 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 Counterintelligence and Security Agency, 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
CITY AND STATE
CONTRACTOR (Typed Name)
THE UNITED STATES OF AMERICA
BY (Signature of Government Representative)
BY (Signature of Authorized Contractor Representative)
AUTHORIZED REPRESENTATIVE OF THE GOVERNMENT
TITLE (of Authorized Contractor Representative)
(Typed Name of Government Agency)
ADDRESS
DD FORM 441-1, MARCH 2020
RESET
PREVIOUS EDITION IS OBSOLETE.