Attachment J.5 AID 500-13 Partner Information Form (PIF) - April 2024 - FINAL.pdf

OMB APPROVAL NO. 0412-0577

EXPIRATION DATE: 04/30/2026

ESTIMATED BURDEN: 90 MINUTES

PARTNER INFORMATION FORM

PART 1: INFORMATION ABOUT PRIME AWARD

1.1 Legal Name of Prospective Awardee (Prime Contractor/Recipient)

1.2 Address of Prospective Awardee

1.3 Alternate Address of Prospective Awardee (if applicable)

1.4 Organization Phone Number (include full

phone number, country code, and area/city code)

1.5 Alternate Phone Number (if applicable)

(include full phone number, country code, and area/city code)

1.6 Fax Number (if applicable) (include full

phone number, country code, and area/city code)

1.7 Organization Email Address 1.8 U.S. Organization? ☐ Yes ☐ No

1.9(a) Value of Total Award (USD) 1.9(b) Solicitation/Award Number

PART 2: INFORMATION ABOUT SUBAWARD (to be completed if submitting a subaward)

2.1 Legal Name of Prospective Subawardee (Subcontractor/Subrecipient)

2.2 Website URL of Prospective Subawardee (if applicable) 2.3 Type of Organization ☐ Parent Organization ☐ Branch ☐ Subsidiary

2.4 Address of Prospective Subawardee

2.5 Alternate Address of Prospective Subawardee (if applicable)

2.6 Organization Phone Number (include full

phone number, country code, and area/city code)

2.7 Alternate Organization Phone Number (if

applicable) (include full phone number, country code, and area/city code)

2.8 Primary Fax Number (if applicable) (include

full phone number, country code, and area/city code)

2.9 Organization Email Address 2.10 U.S. Organization? ☐ Yes ☐ No

2.11 Vetting Category

☐ Subcontract ☐ Subgrant ☐ Training ☐ Equipment ☐ Other:

2.12 Value of Total Subaward (USD) (if applicable)

2.13 Estimated Subaward Start Date (dd-mm-yyyy) 2.14 Estimated Subaward End Date (dd-mm-yyyy)

2.15 Purpose of Subaward

AID 500-13 (04/2024) Page 1 of 8

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.

3.1 Authorizing Official’s Name (First name, Middle name, Last name) 3.2 Title/Organization

3.3 Signature of Authorizing Official 3.4 Date (dd-mm-yyyy)

PART 4a: KEY INDIVIDUAL INFORMATION 4a.1 Name Listed on Government-Issued Photo ID (First name, Middle name(s), Last name)

4a.2 Other Names Used (also known as, nicknames, alias, different spelling) (if applicable)

Place of Birth

4a.3 Village/City 4a.7 Date of Birth (dd-mm-yyyy) 4a.8 Gender on government-issued photo ID

4a.4 District (if applicable)

4a.5 Governorate, Province, or State

4a.9 Country of citizenship (if multiple citizenships, list all countries of citizenship in this block and include additional ID information in the gray boxes below)

4a.6 Country

4a.10 U.S. Citizen? ☐ Yes ☐ No (If yes, provide Passport Number below in “Government-Issued Photo ID Number” section.)

4a.11 U.S. Lawful Permanent Resident?

☐ Yes ☐ No

4a.12 (if yes, include Lawful Permanent Resident Card Number (9 digit A Number#):

4a.13 ID Country of Issuance 4a.13.1 Government-Issued Photo ID Type (please attach clear, legible picture; preferably in color)

4a.13.2 Complete Government-Issued Photo ID Number

4a.14 ID Country of Issuance [complete for multiple citizenship only]

4a.14.1 Government-Issued Photo ID Type [complete for multiple citizenship only] (please attach clear, legible picture; preferably in color)

4a.14.2 Complete Government-Issued Photo ID Number [complete for multiple citizenship only]

4a.15 ID Country of Issuance [complete for multiple citizenship only]

4a.15.1 Government-Issued Photo ID Type [complete for multiple citizenship only] (please attach clear, legible picture; preferably in color)

4a.15.2 Complete Government-Issued Photo ID Number [complete for multiple citizenship only]

4a.16 Address of Residence

4a.17 Province/Region 4a.18 Tribal Affiliation (if applicable)

4a.19 Primary Personal Phone Number (include full phone number, country code, and area/city code)

Is this a cell phone number? ☐ Yes ☐ No

4a.20 Alternate Personal Phone Number (if applicable) (include full phone number, country code, and area/city code)

Is this a cell phone number? ☐ Yes ☐ No 4a.21 Primary Personal Email Address 4a.22 Alternate Personal Email Address (if applicable)

4a.23 Current Employer 4a.24 Organizational Rank or Title

4a.25 Professional Licenses and State-Issued Certifications (if applicable)

AID 500-13 (04/2024) Page 2 of 8

PART 4b: KEY INDIVIDUAL INFORMATION 4b.1 Name Listed on Government-Issued Photo ID (First name, Middle name(s), Last name)

4b.2 Other Names Used (also known as, nicknames, alias, different spelling) (if applicable)

Place of Birth

4b.3 Village/City 4b.7 Date of Birth (dd-mm-yyyy) 4b.8 Gender on government-issued photo ID

4b.4 District (if applicable)

4b.5 Governorate, Province, or State

4b.9 Country of citizenship (if multiple citizenships, list all countries of citizenship in this block and include additional ID information in the gray boxes below)

4b.6 Country

4b.10 U.S. Citizen? ☐ Yes ☐ No (If yes, provide Passport Number below in “Government-Issued Photo ID Number” section.)

4b.11 U.S. Lawful Permanent Resident?

☐ Yes ☐ No

4b.12 (if yes, include Lawful Permanent Resident Card Number (9 digit A Number#):

4b.13 ID Country of Issuance 4b.13.1 Government-Issued Photo ID Type (please attach clear, legible picture; preferably in color)

4b.13.2 Complete Government-Issued Photo ID Number

4b.14 ID Country of Issuance [complete for multiple citizenship only]

4b.14.1 Government-Issued Photo ID Type [complete for multiple citizenship only] (please attach clear, legible picture; preferably in color)

4b.14.2 Complete Government-Issued Photo ID Number [complete for multiple citizenship only]

4b.15 ID Country of Issuance [complete for multiple citizenship only]

4b.15.1 Government-Issued Photo ID Type [complete for multiple citizenship only] (please attach clear, legible picture; preferably in color)

4b.15.2 Complete Government-Issued Photo ID Number [complete for multiple citizenship only]

4b.16 Address of Residence

4b.17 Province/Region 4b.18 Tribal Affiliation (if applicable)

4b.19 Primary Personal Phone Number (include full phone number, country code, and area/city code)

Is this a cell phone number? ☐ Yes ☐ No

4b.20 Alternate Personal Phone Number (if applicable) (include full phone number, country code, and area/city code)

Is this a cell phone number? ☐ Yes ☐ No 4b.21 Primary Personal Email Address 4b.22 Alternate Personal Email Address (if applicable)

4b.23 Current Employer 4b.24 Organizational Rank or Title

4b.25 Professional Licenses and State-Issued Certifications (if applicable)

AID 500-13 (04/2024) Page 3 of 8

PART 4c: KEY INDIVIDUAL INFORMATION 4c.1 Name Listed on Government-Issued Photo ID (First name, Middle name(s), Last name)

4c.2 Other Names Used (also known as, nicknames, alias, different spelling) (if applicable)

Place of Birth

4c.3 Village/City 4c.7 Date of Birth (dd-mm-yyyy) 4c.8 Gender on government-issued photo ID

4c.4 District (if applicable)

4c.5 Governorate, Province, or State

4c.9 Country of citizenship (if multiple citizenships, list all countries of citizenship in this block and include additional ID information in the gray boxes below)

4c.6 Country

4c.10 U.S. Citizen? ☐ Yes ☐ No (If yes, provide Passport Number below in “Government-Issued Photo ID Number” section.)

4c.11 U.S. Lawful Permanent Resident?

☐ Yes ☐ No

4c.12 (if yes, include Lawful Permanent Resident Card Number (9 digit A Number#):

4c.13 ID Country of Issuance 4c.13.1 Government-Issued Photo ID Type (please attach clear, legible picture; preferably in color)

4c.13.2 Complete Government-Issued Photo ID Number

4c.14 ID Country of Issuance [complete for multiple citizenship only]

4c.14.1 Government-Issued Photo ID Type [complete for multiple citizenship only] (please attach clear, legible picture; preferably in color)

4c.14.2 Complete Government-Issued Photo ID Number [complete for multiple citizenship only]

4c.15 ID Country of Issuance [complete for multiple citizenship only]

4c.15.1 Government-Issued Photo ID Type [complete for multiple citizenship only] (please attach clear, legible picture; preferably in color)

4c.15.2 Complete Government-Issued Photo ID Number [complete for multiple citizenship only]

4c.16 Address of Residence

4c.17 Province/Region 4c.18 Tribal Affiliation (if applicable)

4c.19 Primary Personal Phone Number (include full phone number, country code, and area/city code)

Is this a cell phone number? ☐ Yes ☐ No

4c.20 Alternate Personal Phone Number (if applicable) (include full phone number, country code, and area/city code)

Is this a cell phone number? ☐ Yes ☐ No 4c.21 Primary Personal Email Address 4c.22 Alternate Personal Email Address (if applicable)

4c.23 Current Employer 4c.24 Organizational Rank or Title

4c.25 Professional Licenses and State-Issued Certifications (if applicable)

AID 500-13 (04/2024) Page 4 of 8

PART 4d: KEY INDIVIDUAL INFORMATION 4d.1 Name Listed on Government-Issued Photo ID (First name, Middle name(s), Last name)

4d.2 Other Names Used (also known as, nicknames, alias, different spelling) (if applicable)

Place of Birth

4d.3 Village/City 4d.7 Date of Birth (dd-mm-yyyy) 4d.8 Gender on government-issued photo ID

4d.4 District (if applicable)

4d.5 Governorate, Province, or State

4d.9 Country of citizenship (if multiple citizenships, list all countries of citizenship in this block and include additional ID information in the gray boxes below)

4d.6 Country

4d.10 U.S. Citizen? ☐ Yes ☐ No (If yes, provide Passport Number below in “Government-Issued Photo ID Number” section.)

4d.11 U.S. Lawful Permanent Resident?

☐ Yes ☐ No

4d.12 (if yes, include Lawful Permanent Resident Card Number (9 digit A Number#):

4d.13 ID Country of Issuance 4d.13.1 Government-Issued Photo ID Type (please attach clear, legible picture; preferably in color)

4d.13.2 Complete Government-Issued Photo ID Number

4d.14 ID Country of Issuance [complete for multiple citizenship only]

4d.14.1 Government-Issued Photo ID Type [complete for multiple citizenship only] (please attach clear, legible picture; preferably in color)

4d.14.2 Complete Government-Issued Photo ID Number [complete for multiple citizenship only]

4d.15 ID Country of Issuance [complete for multiple citizenship only]

4d.15.1 Government-Issued Photo ID Type [complete for multiple citizenship only] (please attach clear, legible picture; preferably in color)

4d.15.2 Complete Government-Issued Photo ID Number [complete for multiple citizenship only]

4d.16 Address of Residence

4d.17 Province/Region 4d.18 Tribal Affiliation (if applicable)

4d.19 Primary Personal Phone Number (include full phone number, country code, and area/city code)

Is this a cell phone number? ☐ Yes ☐ No

4d.20 Alternate Personal Phone Number (if applicable) (include full phone number, country code, and area/city code)

Is this a cell phone number? ☐ Yes ☐ No 4d.21 Primary Personal Email Address 4d.22 Alternate Personal Email Address (if applicable)

4d.23 Current Employer 4d.24 Organizational Rank or Title

4d.25 Professional Licenses and State-Issued Certifications (if applicable)

AID 500-13 (04/2024) Page 5 of 8

PART 4e: KEY INDIVIDUAL INFORMATION 4e.1 Name Listed on Government-Issued Photo ID (First name, Middle name(s), Last name)

4e.2 Other Names Used (also known as, nicknames, alias, different spelling) (if applicable)

Place of Birth

4e.3 Village/City 4e.7 Date of Birth (dd-mm-yyyy) 4e.8 Gender on government-issued photo ID

4e.4 District (if applicable)

4e.5 Governorate, Province, or State

4e.9 Country of citizenship (if multiple citizenships, list all countries of citizenship in this block and include additional ID information in the gray boxes below)

4e.6 Country

4e.10 U.S. Citizen? ☐ Yes ☐ No (If yes, provide Passport Number below in “Government-Issued Photo ID Number” section.)

4e.11 U.S. Lawful Permanent Resident?

☐ Yes ☐ No

4e.12 (if yes, include Lawful Permanent Resident Card Number (9 digit A Number#):

4e.13 ID Country of Issuance 4e.13.1 Government-Issued Photo ID Type (please attach clear, legible picture; preferably in color)

4e.13.2 Complete Government-Issued Photo ID Number

4e.14 ID Country of Issuance [complete for multiple citizenship only]

4e.14.1 Government-Issued Photo ID Type [complete for multiple citizenship only] (please attach clear, legible picture; preferably in color)

4e.14.2 Complete Government-Issued Photo ID Number [complete for multiple citizenship only]

4e.15 ID Country of Issuance [complete for multiple citizenship only]

4e.15.1 Government-Issued Photo ID Type [complete for multiple citizenship only] (please attach clear, legible picture; preferably in color)

4e.15.2 Complete Government-Issued Photo ID Number [complete for multiple citizenship only]

4e.16 Address of Residence

4e.17 Province/Region 4e.18 Tribal Affiliation (if applicable)

4e.19 Primary Personal Phone Number (include full phone number, country code, and area/city code)

Is this a cell phone number? ☐ Yes ☐ No

4e.20 Alternate Personal Phone Number (if applicable) (include full phone number, country code, and area/city code)

Is this a cell phone number? ☐ Yes ☐ No 4e.21 Primary Personal Email Address 4e.22 Alternate Personal Email Address (if applicable)

4e.23 Current Employer 4e.24 Organizational Rank or Title

4e.25 Professional Licenses and State-Issued Certifications (if applicable)

AID 500-13 (04/2024) Page 6 of 8

PART 4f: KEY INDIVIDUAL INFORMATION 4f.1 Name Listed on Government-Issued Photo ID (First name, Middle name(s), Last name)

4f.2 Other Names Used (also known as, nicknames, alias, different spelling) (if applicable)

Place of Birth

4f.3 Village/City 4f.7 Date of Birth (dd-mm-yyyy) 4f.8 Gender on government-issued photo ID

4f.4 District (if applicable)

4f.5 Governorate, Province, or State

4f.9 Country of citizenship (if multiple citizenships, list all countries of citizenship in this block and include additional ID information in the gray boxes below)

4f.6 Country

4f.10 U.S. Citizen? ☐ Yes ☐ No (If yes, provide Passport Number below in “Government-Issued Photo ID Number” section.)

4f.11 U.S. Lawful Permanent Resident?

☐ Yes ☐ No

4f.12 (if yes, include Lawful Permanent Resident Card Number (9 digit A Number#):

4f.13 ID Country of Issuance 4f.13.1 Government-Issued Photo ID Type (please attach clear, legible picture; preferably in color)

4f.13.2 Complete Government-Issued Photo ID Number

4f.14 ID Country of Issuance [complete for multiple citizenship only]

4f.14.1 Government-Issued Photo ID Type [complete for multiple citizenship only] (please attach clear, legible picture; preferably in color)

4f.14.2 Complete Government-Issued Photo ID Number [complete for multiple citizenship only]

4f.15 ID Country of Issuance [complete for multiple citizenship only]

4f.15.1 Government-Issued Photo ID Type [complete for multiple citizenship only] (please attach clear, legible picture; preferably in color)

4f.15.2 Complete Government-Issued Photo ID Number [complete for multiple citizenship only]

4f.16 Address of Residence

4f.17 Province/Region 4f.18 Tribal Affiliation (if applicable)

4f.19 Primary Personal Phone Number (include full phone number, country code, and area/city code)

Is this a cell phone number? ☐ Yes ☐ No

4f.20 Alternate Personal Phone Number (if applicable) (include full phone number, country code, and area/city code)

Is this a cell phone number? ☐ Yes ☐ No 4f.21 Primary Personal Email Address 4f.22 Alternate Personal Email Address (if applicable)

4f.23 Current Employer 4f.24 Organizational Rank or Title

4f.25 Professional Licenses and State-Issued Certifications (if applicable)

AID 500-13 (04/2024) Page 7 of 8

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 deemed a national security risk.

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-27, 86 FR 3109 (Dec. 5, 2012, modified Jan. 14, 2021)), 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

● Complete all fields and “if applicable” fields if the information exists or applies. For “if applicable” fields, enter “N/A” if not applicable.

● Any prospective awardee must complete a separate form for each prospective subawardee and must complete Parts 2, 3, and

4.

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

● If the request is for trainees/individual beneficiaries, please leave Part # 2 blank, except cells 2.11 - 2.15

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. This certifies that the signer 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.

PART 4: KEY INDIVIDUAL INFORMATION

Please visit www.usaid.gov/partner-vetting for a link to the “USAID Guidance on Completion of the Partner Information Form” documents containing more information on “key individuals.”

AID 500-13 (04/2024) Page 8 of 8 https://www.usaid.gov/partner-vetting