Foreign Disclosure Addendum.docx

Department of Defense (DoD) Small Business Innovation Research (SBIR)/ Small Business Technology Transfer (STTR) Program

FOREIGN DISCLOSURE ADDENDUM

Contractor’s Name

Company Name

Office Tel #

Mobile #

Email

Name of person authorized to sign:

Signature of person authorized:

Date:

The penalty for making false statements is prescribed in the U.S. Criminal Code, 18 U.S.C. 1001.

If your firm answers YES to one or more of the following questions, this form must be completed and included in Volume 5 of the proposal submission.

1. Does your company currently employ any foreign nationals?

☐ YES ☐ NO

2. Does/did your company or employees have relationships with any foreign academic institutions, research centers, or affiliated academic organizations over the past seven (7) years?

☐ YES ☐ NO

3. Has your company received direct or indirect investment or financing from any foreign-based entity?

☐ YES ☐ NO

4. Has your company received direct or indirect investment or financing from any foreign-owned entity domiciled in the US?

☐ YES ☐ NO

5. Has your company received direct or indirect investment or financing from a US entity that manages or receives foreign sources of capital?

☐ YES ☐ NO

6. Does your company have any substantial business operations in other countries?

☐ YES ☐ NO

NOTE: If any additional space is needed in providing answers to the questions below, please attach supplementary pages to the end of the form.

Company

1. Please provide an overview of your company.

2. Please provide an overview of your operations.

3. Please provide a summary of the goods, services, or labor your company provides to the US commercial marketplace.

4. Has your company done business with the US Government before? If so, please provide when, which governmental entity, and a summary of goods, services or labor provided.

5. Does your company have any substantial business operations in other countries? If so, list these offices/company names, locations, and type of structure such as joint ventures, wholly-owned subsidiaries, reseller partners or distributors.

☐ YES ☐ NO

Office/Company Name

6. Does your company provide goods, services, or labor to foreign customers? If so, please provide a summary in the table provided.

☐ YES ☐ NO

Foreign Customer

7. Does your company provide goods, services, or labor to foreign governments? If so, please provide a summary in the table provided.

Foreign Government Goods, Services, or Labor Provided

Leadership

1. Please provide an organization chart of your company and its affiliates.

2. Please provide an updated capitalization table of your company’s ownership structure that captures the absolute parent, all subsidiaries, all joint ventures, and all affiliate companies over the past five (5) years. This includes any direct or indirect beneficial owners or entities.

3. Do any foreign nationals (or dual-citizenship holders) sit on your board of directors (or similar governing body)?

☐ YES ☐ NO

4. Do any foreign nationals hold roles as officers, executive personnel, general partners, regents, trustees, or senior management officials? If so, please provide name, country of residence, country of citizenship, role/capacity within your company.

☐ YES ☐ NO

5. Do any of your board members, officers, executive personnel, general partners, regents, trustees, or senior management officials serve as an employee, consultant, or advisor, in any capacity, to a foreign company? If so, please provide details, such as names of personnel, name and location of the foreign entity and the role / position those individual(s) have with said entity. Please also provide resumes and/or CVs for these individuals.

☐ YES ☐ NO

NOTE: If your proposal is selected for negotiation and possible award, you will be required to provide the Contracting Officer personally identifiable information for all executives, senior leaders, and board members (name, date of birth, social security number; for foreign nationals, please provide relevant visa or immigration information).

Employees

1. Does your company currently employ any foreign nationals? If so, please provide a list of names, roles, country(ies) of residence, and country(ies) of citizenship. Please also provide resumes and/or CVs for these individuals.

2. Does your company have employees in overseas facilities or working remotely from an overseas location? If so, please provide names, roles, country(ies) of residence, and country(ies) of citizenship. Please also provide resumes and/or CVs for these individuals.

3. In the last seven years, have any of your employees worked for a foreign government? If so, please provide details to include employee name(s), their previous position and area of responsibility, dates of employment and specific government department or organization Please also provide resumes and/or CVs for these individuals.

4. In the last seven years, have any of your employees worked overseas for a foreign company? If so, please provide details, to include employee name(s), name and location of foreign company, and position. Please also provide resumes and/or CVs for these individuals.

5. Does your company hire interns, temporary employees, or employees not considered full-time employees? Please also provide resumes and/or CVs for these individuals.

☐ YES ☐ NO

Relationships

1. Please provide an overview of your company’s foreign relationships.

2. Does your company have any foreign joint ventures or unannounced foreign branches?

☐ YES ☐ NO

3. Has your company ever provided goods, services, or labor to a foreign government? Please provide details of this relationship.

☐ YES ☐ NO

Foreign Government Goods, Services, or Labor Provided

4. Has your company ever provided goods, services, or labor to a foreign government as a sub-contractor, indirect supplier, reseller, or wholesaler? Please provide details of this relationship.

☐ YES ☐ NO

Foreign Government

5. Does your company currently have any contracts or provide any goods, services, or labor to any foreign companies? If so, please provide details.

☐ YES ☐ NO

Foreign Company

6. Does your company belong to any professional societies, affiliations, clubs, or organizations? If so, please provide details.

☐ YES ☐ NO

Professional Society, Affiliation, Club, or Organization Name Nature of Involvement

7. Does your company collaborate with any academic institutions, research centers, or affiliates? If so, please provide details.

☐ YES ☐ NO

Academic Institution, Research Center, or Affiliate Name Details on Collaboration

8. Please provide a list of all international conferences, events, and gatherings your company attended over the past three years.

Event

9. Does your company currently have any national security agreements with:

a. The US Government?

☐ YES ☐ NO

b. A foreign government? If so, please list.

☐ YES ☐ NO

10. Please provide an overview of your company’s growth strategy over the next five years to include targeted industries, regions, and new markets.

Financial

1. Please provide a copy of a government-issued business license from the state of incorporation.

2. Please provide a list of investments received by your company from private investors.

3. Do any foreign persons or entities directly or indirectly own or have beneficial ownership of five percent or more of your company’s equity or shares?

☐ YES ☐ NO

4. Has your company received investment or financing from any foreign-based entity? If yes, list them.

☐ YES ☐ NO

Foreign Entity Name

5. Has your company received investment or financing from any foreign-owned entity domiciled in the US? If yes, list them.

☐ YES ☐ NO

Foreign Entity Name Summary of Investment/Financing

6. Has your company received investment or financing from a US entity that manages or receives foreign sources of capital?

☐ YES ☐ NO

7. Does your company have investment from special purpose vehicles? If so, list them and their funding sources.

☐ YES ☐ NO

Name Funding Sources

8. Do any of your investors use Chinese raised capital?

☐ YES ☐ NO

9. Does your company, whether as a borrower, surety, guarantor, or otherwise, have any indebtedness, liabilities, or obligations to a foreign person, entity, or financial institution? If so, please provide details.

☐ YES ☐ NO

10. In the last five years, did more than 5% of your net income come from any single country or company? If so, please provide details.

☐ YES ☐ NO

11. In the last five years, did more than 25% of your net income come from multiple foreign individuals or companies? If so, please provide details.

☐ YES ☐ NO

12. Do any entities own 10% or more of your company? If so, please provide details.

☐ YES ☐ NO

13. Which bank(s) service your company? In what capacity?

14. Who is your company’s auditor?

15. Which lawyer/law firm represents your company?

Suppliers

1. Please list the foreign countries which directly supply your company with goods, services, or labor.

☐ NONE

2. Please list the types of goods, services, or labor directly supplied to your company from foreign companies or companies located in foreign countries.

☐ NONE

3. Does your company conduct supply chain risk analysis?

☐ YES ☐ NO

4. Does your company conduct due diligence or background checks on suppliers?

☐ YES ☐ NO

5. Does your company review Office of Foreign Assets Control (OFAC) sanctioned countries while considering suppliers?

☐ YES ☐ NO

6. Does your company, either in the US or overseas, contract directly with companies headquartered in Russia, China, Iran, or OFAC sanctioned countries?

☐ YES ☐ NO

7. Does your company have contingency plans for alternate suppliers or stockpile critical supplies?