72026720R00001 J.3 Partner Information Form AID 500-13.doc

OMB 0412-0577

EXPIRATION DATE: 04/30/19

PARTNER INFORMATION FORM

(See Burden and Privacy Act Statements on Page 3) Part I: Information About Proposed Activities

1. Name of the prime contractor, grantee or recipient proposing the award or other assistance

a. Name of Parent Company (if any)*:

b. Company website URL*:

2. Type of proposed award or other assistance (check one)*:

FORMCHECKBOX

Contract or Subcontract FORMCHECKBOX Grant or Subgrant FORMCHECKBOX Training FORMCHECKBOX Equipment FORMCHECKBOX Other

3. US$ amount and estimated start/end date of proposed award or assistance*:

Dollar amount: $ Start: End:

4. Purpose of proposed award or assistance*:

a. Location of Proposed Activity – Country*: State*: Province/Region*:

5. Organization proposed to receive award or other assistance*:

a. Name*:

b. Address*:

6. Information on key individuals associated with the organization named in 5 above, or, if no organization is listed, information on each individual to receive cash or in-kind assistance (including technical assistance). Use continuation sheets as necessary.

i.. Name (As in passport or other government-issued photo ID):* Government-issued photo ID number, type of ID and country of issuance:*

Place of birth:* Date of birth:* (mm/dd/yyyy) Rank or title in organization listed in #5 (if “key individual”):*

Other names used (may include nicknames, pseudonyms not listed under “Name”):*

Gender:

Current employer and job title:

Occupation:

Address of residence:

Citizenship(s):

Province/Region:

Tribal Affiliation (if any):

Email:

Is the individual a U.S. citizen or legal permanent resident?* Yes FORMCHECKBOX No FORMCHECKBOX

Alternate Email:

Professional Licenses – State Issued Certifications:

Part II: Contractor/Grantee/Recipient Certification:

Contractor/Grantee/Recipient certifies in submitting this form that it has taken reasonable steps (in accordance with sound business practices) to verify the information contained in this form. Contractor/Grantee/Recipient understands that the U.S. Government may rely on the accuracy of such information in processing this vetting request.

Name:

Signature:

Title/Organization:

Date:

Part III: Submission details (to be completed by USG vetting official)

Partner Information Form Continuation Sheet for Part I, Section 6: List of Individuals (Use additional continuation sheets as necessary):

ii. Name (As in passport or other government-issued photo ID):* Government-issued photo ID number, type of ID and country of issuance:*

Place of birth:* Date of birth:* (mm/dd/yyyy) Rank or title in organization listed in #5 (if “key individual”):*

Other names used (may include nicknames, pseudonyms not listed under “Name”):*

Gender:

Current employer and job title:

Occupation:

Address of residence:

Citizenship(s):

Province/Region:

Tribal Affiliation (if any):

Email:

Is the individual a U.S. citizen or legal permanent resident?* Yes FORMCHECKBOX

Alternate Email:

Professional Licenses:

iii. Name (As in passport or other government-issued photo ID):* Government-issued photo ID number, type of ID and country of issuance:*

Place of birth:* Date of birth:* (mm/dd/yyyy) Rank or title in organization listed in #5 (if “key individual”):*

Other names used (may include nicknames, pseudonyms not listed under “Name”):*

Gender:

Current employer and job title:

Occupation:

Address of residence:

Citizenship(s):

Province/Region:

Tribal Affiliation (if any):

Email:

Is the individual a U.S. citizen or legal permanent resident?* Yes FORMCHECKBOX

Alternate Email:

Professional Licenses:

iv. Name (As in passport or other government-issued photo ID):* Government-issued photo ID number, type of ID and country of issuance:*

Place of birth:* Date of birth:* (mm/dd/yyyy) Rank or title in organization listed in #5 (if “key individual”):*

Other names used (may include nicknames, pseudonyms not listed under “Name”):*

Gender:

Current employer and job title:

Occupation:

Address of residence:

Citizenship(s):

Province/Region:

Tribal Affiliation (if any):

Email:

Is the individual a U.S. citizen or legal permanent resident?* Yes FORMCHECKBOX

Alternate Email:

Professional Licenses:

v. Name (As in passport or other government-issued photo ID):* Government-issued photo ID number, type of ID and country of issuance:*

Place of birth:* Date of birth:* (mm/dd/yyyy) Rank or title in organization listed in #5 (if “key individual”):*

Other names used (may include nicknames, pseudonyms not listed under “Name”):*

Gender:

Current employer and job title:

Occupation:

Address of residence:

Citizenship(s):

Province/Region:

Tribal Affiliation (if any):

Email:

Is the individual a U.S. citizen or legal permanent resident?* Yes FORMCHECKBOX

Alternate Email:

Professional Licenses:

* Indicates mandatory information

PARTNER INFORMATION FORM INSTRUCTIONS

Part I

Question 1 – Self-explanatory

Question 2- Indicate the proposed type of mechanism to be utilized by placing a check mark on the line in front of the appropriate term

Question 3 – Enter the amount of award or assistance in U.S. dollars and indicate the start and end date of the program using a mm/dd/yyyy format

Question 4 – Indicate the purpose of the award or assistance. Use additional sheets and attach to page one of the vetting form if necessary

Question 5 a-e – Self-explanatory

Question 6 - “Key individual” means (i) principal officers of the organization’s governing body (e.g., chairman, vice chairman, treasurer and secretary of the board of directors or board of trustees); (ii) the principal officer and deputy principal officer of the organization (e.g., executive director, deputy director, president, vice president); (iii) the program manager or chief of party for the USG-financed program; and (iv) any other person with significant responsibilities for administration of the USG-financed activities or resources. Note that this definition differs from the definition of “key personnel” under contracts and cooperative agreements. Complete for each of these four categories or indicate “N/A” if a category does not apply.

Part II

Individual filling out form must read the Certification and print their name where indicated, sign where indicated, print their title and the name of their organization where indicated, and print the date where indicated.

Part III

This section is not for individual’s information and will be completed by the USG vetting official.

PUBLIC BURDEN STATEMENT

Public reporting burden for this collection of information is estimated to average 75 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. The Agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the U.S. Agency for International Development, Office of Security (SEC), Washington, D.C. 20523-2600.

PRIVACY ACT STATEMENT

Authority: Public Law 109-446 §3(b)(2), 120 Stat. 3318, 3322 (Dec. 21, 2006); 18 U.S.C. 2339A, 2339B, 2339C; Executive Orders 13224 and 12947, applicable Homeland Security Presidential Directives and other legislative or executive branch prohibitions on providing support or resources to, or engaging in transactions with, individuals or entities associated with terrorism constitute the authority for collecting this information; Foreign Assistance Act of 1961 as amended (22 U.S.C. 2151 et seq.).

Purpose: Information in this form is used to conduct screening of individuals and entities as required by applicable U.S. laws and implementing procedures to ensure that USAID funds do not inadvertently provide support to entities or individuals associated with terrorism.

Routine Uses: Disclosure of the information provided on this form will be done in accordance with the Privacy Act, as well as with USAID’s System of Records Notice concerning the Partner Vetting System (USAID-29, 77 FR 72319 (Dec. 5, 2012)), which establishes the routine uses and Privacy Act exceptions that apply to this system of records.

Disclosure: Providing personal information is voluntary, but failure to provide certain information may result in denial of your application for USAID a contract, grant, cooperative agreement, or other funding, or for registration with USAID as a Private and Voluntary Organization (PVO).

AID 500-13 (05/2016) Page 5 of 5

* = mandatory information.