DS-4184.pdf

I certify that I have taken reasonable steps (in accordance with sound business practices) to verify the information contained in this form. I understand that the U.S. Government may rely on the accuracy of such information in processing this request.

PART 3: CERTIFICATION

Authorizing Official's Name (Last, First, MI) Title/Organization

DS-4184

08-2022

Signature Date (mm-dd-yyyy)

PART 2: AFGHANISTAN

Afghanistan Business License Number Joint Contingency Contracting System (JCCS) Number

Please provide the following information if proposed contract or grant work will be in Afghanistan.

Phone Number Cell Phone Number E-mail Address

Address of Prospective Contractor/Grantee

Type (Contract, Grant, Other):Name of Prospective Contractor/Grantee

PART 1: INFORMATION ABOUT CONTRACT/GRANT/COOPERATIVE AGREEMENT

US Dollar Value of Contract/Grant (All Years) Contract/Grant Start Date (mm-dd-yyyy) Contract/Grant End Date (mm-dd-yyyy) Solicitation Number

Purpose of Contract/Grant

U.S. Department of State

RISK ANALYSIS INFORMATION

OMB APPROVAL NO. 1405-0204

EXPIRES: 03/31/2026

ESTIMATED BURDEN: 90 Minutes*

Contract Grant Other

Country of IssuanceTazkera Number Passport Number

Father's Name Tribe

Afghan Citizen Use Only (If Section 2 Has Been Completed)

Home Address

Current Employer

National ID Type

KEY INDIVIDUAL INFORMATION #1

Name (Last, First, MI)

Place of Birth (City, State, Province, Country)

Citizenship(s)

Organizational Title

Page 2 of 3DS-4184

Home Phone Cell Phone Number

Social Media Handles/Identifiers E-mail Address

Current Employer Phone

Project Title

National ID Number Country of Issuance

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

Date of Birth (mm-dd-yyyy) Gender:

Male Female

U.S. citizen or Permanent Legal Resident? Yes No

If yes, provide your U.S. Passport or Social Security Number

Current Employer Address

Country of IssuanceTazkera Number Passport Number

Father's Name Tribe

Afghan Citizen Use Only (If Section 2 Has Been Completed)

Home Address

Current Employer

National ID Type

KEY INDIVIDUAL INFORMATION #2

Name (Last, First, MI)

Place of Birth (City, State, Province, Country)

Citizenship(s)

Organizational Title

Home Phone Cell Phone Number

Social Media Handles/Identifiers E-mail Address

Current Employer Phone

Project Title

National ID Number Country of Issuance

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

Date of Birth (mm-dd-yyyy) Gender:

Male Female

U.S. citizen or Permanent Legal Resident? Yes No

If yes, provide your U.S. Passport or Social Security Number

Current Employer Address

Purpose: The information in the system supports the vetting of directors, officers, or other employees of organizations who apply for Department of State contracts, grants, or other funding. The information collected from the organizations and individuals is specifically used to conduct screening to ensure that Department funds are not used to provide support to entities or individuals deemed to be a risk to US national security interests.

Routine Uses: The information is used to make determinations on applications for contracts, grants or other funding and may be disclosed to the United States Agency for International Development (USAID) and other government agencies for collaborative vetting programs. For additional details on Routine Uses not listed here, refer to the Department of State's System of Record Notice concerning the Risk Analysis and Management System (RAM) (State 78).

Disclosure: Providing the information is voluntary. Failure to provide the information will result in a finding of ineligibility for Department funding.

Appendix Key Individuals or Recipients (Use continuation sheets, as necessary)

Key individuals may include but are not limited to:

The organization/company's President, Vice President, Executive Director, Deputy Executive Director, Chief Executive Officer, Chief Operating Officer, Treasurer, Secretary, and the Board of Directors.

Individual who may benefit from or participate in a U.S.-funded program, for example, as an attendee at a U.S. government-sponsored training session.

It may also include Program Managers or Project Managers.

Proposed Subcontractors or Sub-grantees must also complete a separate Information Form listing their key personnel.

Indicate "N/A" if a category does not apply. If no organization or company is listed, complete the information on each individual who will receive cash or in-kind assistance (including technical assistance).

Recipients may include but are not limited to:

INSTRUCTIONS

Page 3 of 3DS-4184

PAPERWORK REDUCTION ACT STATEMENT

*Public reporting burden for this collection of information is estimated to average 90 minutes per response, including time required for searching existing data sources, gathering the necessary documentation, providing the information and/or documents required, and reviewing the final collection.

You do not have to supply this information unless this collection displays a current valid OMB control number. If you have comments on the accuracy of this burden estimate and/or recommendations for reducing it, please send them to: U.S. Dept. of State, 2201 C St. NW, SA-15 room 3200, Washington, DC 20520.

PRIVACY ACT STATEMENT

Authority: 18 U.S.C. 2339A, 2339B, 2339C; 22 U.S.C. 2151 et seq.; Section 219 of the Immigration and Nationality Act (INA) (P.L. 104-132) (8 U.S.C. 1189); Executive Orders 13224, 13099 and 12947; Homeland Security Presidential Directive 6; Section 7034(f) of the Department of State, Foreign Operations, and Related Programs Appropriations Act, 2022 (Div. K, P.L. 117-103) and similar provisions in prior appropriations acts.