Attachment 10: Lautenberg Amendment IAW 18 USC 922 and Certification Form

15 June 2026

SIR No. 69M215-25-R-00012

Attachment 10
Lautenberg Amendment IAW 18 USC 922 – Annual Certification Form

ANNUAL QUALIFICATION INQUIRY – 20XX

LAUTENBERG AMENDMENT

ARMED GUARD CONTRACT - 692M15-TBD

In completing this form, you are advised: The purpose is to obtain information, which will assist in the determination of whether personnel reassignment and/or administrative action are warranted. You have a duty to complete this form. Agency disciplinary action, including dismissal, may be undertaken if you refuse to answer or if you fail to reply fully and truthfully. Neither your answers nor any information or evidence gained by reason of your answers can be used against you in any criminal prosecution for a violation of Title 18, United States Code, Section 922(g)(9)-attached. However, the answers you furnish and any information or evidence resulting therefrom may be used against you in a prosecution for knowingly and willfully providing false statements or information, and in the course of agency disciplinary proceedings. 1. Have you ever been convicted of a misdemeanor crime of domestic violence within the meaning of the statute? Initial and date: YES

NO

2. If you answered YES to the question, provide the following information with respect to the conviction. Court/jurisdiction:
Docket/Case Number:
Statute/Charge:
Date Sentenced
I hereby certify that, to the best of my information and belief, all of the information provided by me is true, correct, complete, and made in good faith. I understand that false or fraudulent information provided herein may be grounds for adverse action, up to and including removal, and is also criminally punishable pursuant to federal law, including 18 USC Section 1001.
Name:
(print or type)
Signature
Duty Station:_FAA William J Hughes Technical Center for Advanced Aerospace, Atlantic City Int’l Airport, Atlantic City NJ_

Signature
Program Manager

Date