Annex III. USAID Partner Information Form.docx

OMB APPROVAL NO. 0412-0577 EXPIRATION DATE: 12/31/2022

ESTIMATED BURDEN: 90 MINUTES

PARTNER INFORMATION FORM

PART 1: INFORMATION ABOUT AWARD

Name of Prospective Awardee (Prime Contractor/Grantee/Recipient)*

Address of Prospective Awardee*

Organization Phone Number*

Cell Phone Number* Primary Fax Number

Organization Email Address* Alternate Email Address

Type of Award* |_| Contract |_| Grant |_| Training |_| Equipment |_| Other:

Value of Total Award (USD)* Award Start Date (mm-dd-yyyy)* Award End Date (mm-dd-yyyy)* Solicitation/Award Number

Purpose of Award*

Location of Proposed Activity

Country*: State*: Province/Region*:

PART 2: INFORMATION ABOUT SUBAWARD**

Name of Prospective Subawardee (Subcontractor/Subgrantee/Subrecipient) |_| Parent Organization |_| Branch |_| Subsidiary Website URL of Prospective Subawardee

Address of Prospective Subawardee

Organization Phone Number

Cell Phone Number Primary Fax Number

Organization Email Address Alternate Email Address

Type of Subaward |_| Subcontract |_| Subgrant |_| Training |_| Equipment |_| Other:

Value of Total Subaward (USD) (if applicable)

Purpose of Subaward

PART 3: CERTIFICATION

The prospective awardee certifies in submitting this form that it has taken reasonable steps in accordance with sound business practices to verify information included in this form and understands that the U.S. government may rely on the accuracy of such information to process this request.

Authorizing Official’s Name (Last, First, Middle Initial)

Title/Organization

Signature

Date (mm-dd-yyyy)

* = mandatory information ** = The entire form, including Part 2, must be completed for each prospective subawardee. AID 500-13 (12/2022)

PART 4: KEY INDIVIDUAL INFORMATION

Name Listed on Government-Issued Photo ID (Last, First, Middle Initial)*

Other Names Used (Also known as, nicknames, alias, different spelling)*

Place of Birth* Date of Birth (mm-dd-yyyy)* Gender

Citizenship(s) (If dual citizen, list both countries)* U.S. Citizen or Permanent Resident?* |_| Yes |_| No If yes, U.S. Passport/Permanent Resident Card Number:

Government-Issued Photo ID Type* Government-Issued Photo ID Number* ID Country of Issuance*

Government-Issued Photo ID Type [complete for dual citizens only] Government-Issued Photo ID Number [complete for dual citizens only] ID Country of Issuance [complete for dual citizens only]

Address of Residence

Province/Region

Tribal Affiliation (if applicable)

Primary Phone Number*

Is this a cell phone number? |_| Yes |_| No Alternate Phone Number

Is this a cell phone number? |_| Yes |_| No

Primary Email Address* Alternate Email Address

Current Employer and Project Title* Organizational Rank or Title*

Occupation Professional Licenses and State-Issued Certifications

KEY INDIVIDUAL INFORMATION

Name Listed on Government-Issued Photo ID (Last, First, Middle Initial)*

Other Names Used (Also known as, nicknames, alias, different spelling)*

Place of Birth* Date of Birth (mm-dd-yyyy)* Gender

Citizenship(s) (If dual citizen, list both countries)* U.S. Citizen or Permanent Resident?* |_| Yes |_| No If yes, U.S. Passport/Permanent Resident Card Number:

Government-Issued Photo ID Type* Government-Issued Photo ID Number*

ID Country of Issuance*

Government-Issued Photo ID Type

Government-Issued Photo ID Number [complete for dual citizens only] ID Country of Issuance [complete for dual citizens only]

Address of Residence

Province/Region

Tribal Affiliation (if applicable)

Primary Phone Number*

Is this a cell phone number? |_| Yes |_| No Alternate Phone Number

Is this a cell phone number? |_| Yes |_| No

Primary Email Address* Alternate Email Address

Current Employer and Project Title* Organizational Rank or Title*

Occupation Professional Licenses and State-Issued Certifications

KEY INDIVIDUAL INFORMATION

Name Listed on Government-Issued Photo ID (Last, First, Middle Initial)*

Other Names Used (Also known as, nicknames, alias, different spelling)*

Place of Birth* Date of Birth (mm-dd-yyyy)* Gender

Citizenship(s) (If dual citizen, list both countries)* U.S. Citizen or Permanent Resident?* |_| Yes |_| No If yes, U.S. Passport/Permanent Resident Card Number:

Government-Issued Photo ID Type* Government-Issued Photo ID Number* ID Country of Issuance*

Government-Issued Photo ID Type

Government-Issued Photo ID Number [complete for dual citizens only] ID Country of Issuance [complete for dual citizens only]

Address of Residence

Province/Region

Tribal Affiliation (if applicable)

Primary Phone Number*

Is this a cell phone number? |_| Yes |_| No Alternate Phone Number

Is this a cell phone number? |_| Yes |_| No

Primary Email Address* Alternate Email Address

Current Employer and Project Title* Organizational Rank or Title*

Occupation Professional Licenses and State-Issued Certifications

KEY INDIVIDUAL INFORMATION

Name Listed on Government-Issued Photo ID (Last, First, Middle Initial)*

Other Names Used (Also known as, nicknames, alias, different spelling)*

Place of Birth* Date of Birth (mm-dd-yyyy)* Gender

Citizenship(s) (If dual citizen, list both countries)* U.S. Citizen or Permanent Resident?* |_| Yes |_| No If yes, U.S. Passport/Permanent Resident Card Number:

Government-Issued Photo ID Type* Government-Issued Photo ID Number* ID Country of Issuance*

Government-Issued Photo ID Type

Government-Issued Photo ID Number [complete for dual citizens only] ID Country of Issuance [complete for dual citizens only]

Address of Residence

Province/Region

Tribal Affiliation (if applicable)

Primary Phone Number*

Is this a cell phone number? |_| Yes |_| No Alternate Phone Number

Is this a cell phone number? |_| Yes |_| No

Primary Email Address* Alternate Email Address

Current Employer and Project Title* Organizational Rank or Title*

Occupation Professional Licenses and State-Issued Certifications

KEY INDIVIDUAL INFORMATION

Name Listed on Government-Issued Photo ID (Last, First, Middle Initial)*

Other Names Used (Also known as, nicknames, alias, different spelling)*

Place of Birth* Date of Birth (mm-dd-yyyy)* Gender

Citizenship(s) (If dual citizen, list both countries)* U.S. Citizen or Permanent Resident?* |_| Yes |_| No If yes, U.S. Passport/Permanent Resident Card Number:

Government-Issued Photo ID Type* Government-Issued Photo ID Number* ID Country of Issuance*

Government-Issued Photo ID Type

Government-Issued Photo ID Number [complete for dual citizens only] ID Country of Issuance [complete for dual citizens only]

Address of Residence

Province/Region

Tribal Affiliation (if applicable)

Primary Phone Number*

Is this a cell phone number? |_| Yes |_| No Alternate Phone Number

Is this a cell phone number? |_| Yes |_| No

Primary Email Address* Alternate Email Address

Current Employer and Project Title* Organizational Rank or Title*

Occupation Professional Licenses and State-Issued Certifications

KEY INDIVIDUAL INFORMATION

Name Listed on Government-Issued Photo ID (Last, First, Middle Initial)*

Other Names Used (Also known as, nicknames, alias, different spelling)*

Place of Birth* Date of Birth (mm-dd-yyyy)* Gender

Citizenship(s) (If dual citizen, list both countries)*

U.S. Citizen or Permanent Resident?* |_| Yes |_| No If yes, U.S. Passport/Permanent Resident Card Number:

Government-Issued Photo ID Type* Government-Issued Photo ID Number* ID Country of Issuance*

Government-Issued Photo ID Type

Government-Issued Photo ID Number [complete for dual citizens only] ID Country of Issuance [complete for dual citizens only]

Address of Residence

Province/Region

Tribal Affiliation (if applicable)

Primary Phone Number*

Is this a cell phone number? |_| Yes |_| No Alternate Phone Number

Is this a cell phone number? |_| Yes |_| No

Primary Email Address* Alternate Email Address

Current Employer and Project Title* Organizational Rank or Title*

Occupation Professional Licenses and State-Issued Certifications

PAPERWORK REDUCTION ACT STATEMENT

Public reporting burden for this collection of information is estimated to average 90 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: USAID derives its authority to collection information for vetting purposes from, among other sources, Executive Order 13224; Section 7034(e) of the Consolidated Appropriations Act, 2018 (P.L. 115-141), and subsequent appropriations acts; and 18 U.S.C. 2339A, 2339B, and 2339C.

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 help ensure that USAID funds do not inadvertently provide support to individuals or entities 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 personally identifiable information is voluntary, but failure to provide certain information may result in denial of your application for a USAID contract, grant, cooperative agreement, or other funding.

INSTRUCTIONS

· Fields marked by an asterisk (*) are mandatory and must be completed. All remaining fields must be completed if applicable.

· Any prospective awardee completing the form on its own behalf must provide information on the prospective awardee, award, and their key individuals by completing the entire form EXCEPT Part 2.

· Any prospective awardee must complete a separate form for each prospective subawardee and must provide information on the prospective subawardee, award, and their key individuals by completing the entire form, including Part 2.

· If the prospective awardee/subawardee is a branch organization, a separate form must be completed for the parent organization.

· Indicate “N/A” (not applicable) if a category does not apply.

· If applicable, provide the house/building number, street name, village/city, district, province/governorate/state, and country in the appropriate fields.

· Dual citizens must provide identification information from both countries of citizenship.

· This form may be used to collect information once an award has been made. In such instances, information must be provided for the awardee/subawardee and their key individuals.

PART 1: INFORMATION ABOUT AWARD

Enter information on awardee and on award or assistance.

PART 2: INFORMATION ABOUT SUBAWARD

Enter information on subawardee and subaward if applicable.

PART 3: CERTIFICATION

The authorizing official must complete the certification section by printing their name, title and name of organization, signing their name, and printing the date where indicated.

PART 4: KEY INDIVIDUAL INFORMATION

“Key Individual” is defined as follows:

1. 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);

2. The principal officer and deputy principal officer of the organization (e.g., executive director, deputy director, president, or vice president);

3. The program manager or chief of party for the USAID-financed program; and

4. Any other person with significant responsibilities for administration of the USAIDfinanced activities or resources, such as key personnel as described in either Automated Directives System (ADS) Chapter 302 for contracts or ADS Chapter 303 for assistance awards.

The definition of “Key Individual” differs from, and is generally broader than, the definition of “Key Personnel” used in USAID Assistance and Acquisition policy, although there is some overlap. The term “Key Individual” is designed to include (a) high-level members of the firm’s management and governance body holding positions of the type identified in the definition; and (b) personnel with significant responsibilities for administration of USAID-financed activities or resources. These categories include, but are not limited to, certain members of an organization’s governing body and principal officers. In cases where an organization has a field office managing a USAID award, Key Individuals will include the awardee’s Chief of Party or program manager. In addition, persons with significant responsibilities for administration of USAID-financed activities or resources should be included as Key Individuals on this Partner Information Form.

* = mandatory information ** = The entire form, including Part 2, must be completed for each prospective subawardee. AID 500-13 (12/2022) image1.jpg