Foreign Disclosures.pdf

Appendix III: Required Disclosures of Foreign Affiliations or Relationships to Foreign

Countries

Relevant Definitions

Covered individual - the term "covered individual" means an individual who-

(A) contributes in a substantive, meaningful way to the scientific development or execution of a research and development project proposed to be carried out with a research and development award from a federal research agency; and

(B) is designated as a covered individual by the federal research agency concerned.

Foreign affiliation - the term "foreign affiliation" means a funded or unfunded academic, professional, or institutional appointment or position with a foreign government or government-owned entity, whether full-time, part-time, or voluntary. This includes appointments or positions deemed adjunct, visiting, or honorary with research institutions located in a foreign country of concern.

Foreign country of concern - the term "foreign country of concern" means the People's

Republic of China, the Democratic People's Republic of Korea, the Russian Federation, the

Islamic Republic of Iran, or any other country determined to be a country of concern by the

Secretary of State.

Malign foreign talent recruitment program - the term "malign foreign talent recruitment program" has the meaning given such term in section 19237 of title 42.

Federally funded award - the term "federally funded award" means a Phase I, Phase II

(including a Phase II award under subsection (cc)), or Phase III SBIR or STTR award made using a funding agreement.

Applicant or awardee Name: ________________________________________

Applicant or awardee EIN (UEI if EIN is unavailable): __________________

Responses to disclosure questions may contain trade secrets or commercial or financial information that is privileged or confidential and is exempt from public disclosure. Such information shall be used or disclosed only for evaluation purposes or in accordance with an award between the submitter and the Government.

An up-to-date list of countries determined to be countries of concern by the Secretary of State will be maintained and accessible on SBIR.gov.

Disclosure Questions

1. Is any owner or covered individual of the applicant or awardee party to any malign foreign talent recruitment program?

☐ Yes ☐ No

If yes, disclose the first and last name of each owner or covered individual, identify their role (i.e., owner or covered individual), and the malign foreign talent recruitment program.

2. Is there a parent company, joint venture, or subsidiary, of the applicant or awardee that is based in or receives funding from, any foreign country of concern?

☐ Yes ☐ No

If yes, disclose the name, full address, applicant or awardee relationships (i.e., parent company, joint venture, or subsidiary) of each entity based in, or funded by, any foreign country of concern.

3. Does the applicant or awardee have any current or pending contractual or financial obligation or other agreement specific to a business arrangement, or joint venture-like arrangement with an enterprise owned by a foreign state or any foreign entity?

☐ Yes ☐ No

If yes, disclose the name of each enterprise or foreign entity, type of obligation, agreement, or arrangement (i.e., contractual, financial, or other), description of obligation, agreement, or arrangement, and the foreign state(s) and/or the country of the foreign entity (or entities).

4. Is the applicant or awardee wholly owned in a foreign country?

☐ Yes ☐ No

If yes, disclose the foreign country.

5. Does the applicant or awardee have any venture capital or institutional investment?

☐ Yes ☐ No

If yes, proceed to question 5a. If no, proceed to question 6.

5a. Does the investing entity have a general partner or any other individual holding a leadership role who has a foreign affiliation with any foreign country of concern?

☐ Yes ☐ No ☐ Unable to determine

If yes or unable to determine, disclose the venture capital or institutional investing entity’s name, the percentage of ownership obtained by the investingentity, and the type of investment (i.e., equity, debt, or combination of equity and debt).

6. During the previous 5-year period, did the applicant or awardee have any technology licensing or intellectual property sales or transfers, to a foreign country of concern?

☐ Yes ☐ No If yes, disclose the name, address, and country, of the institution or entity that licensed, purchased, or received the technology or intellectual property.

7. Is there any foreign business entity, offshore entity, or entity outside the United States related to the applicant or awardee?

☐ Yes ☐ No If yes, disclose the entity name, relationship type (i.e., foreign business entity, offshore entity, entity outside the United States), description of the relationship to the applicant or awardee, and entity address and country.

8. Does the applicant or awardee have an owner, officer, or covered individual that has a foreign affiliation with a research institution located in a foreign country of concern?

☐ Yes ☐ No

If yes, disclose the first and last name of each owner, officer, or covered individual that has a foreign affiliation with a foreign country of concern, identify their role (i.e., owner, officer, or covered individual), and the name of the foreign research institution and the foreign country of concern where it is located.

CERTIFICATION

I certify to the best of my knowledge and belief that the information contained in this Disclosure of Foreign Relationships is true, complete, and accurate. I understand that any false, fictitious, or fraudulent information, misrepresentations, half-truths, or omissions of any material fact, may subject me to criminal, civil or administrative penalties for fraud, false statements, false claims or otherwise. (18 U.S.C. §§ 1001 and 287, and 31 U.S.C. 3729-3733 and 3801-3812).

I understand that the small business concern will be required to repay all amounts received under the award if there is a material misstatement that DOE determines poses a risk to national security, or there is a change in ownership, change to entity structure, or other substantial change in the circumstances of the small business concern that DOE determines poses a risk to national security. (15 U.S.C. § 638(g), (o)).

I further understand and agree that (1) the statements and representations made herein are material to DOE’s funding decision, and (2) I have a responsibility to update the disclosures during the period of performance of the award if: (i) there is any change to a disclosure required under questions 1-7, (ii) there is any material misstatement that DOE could determine poses a risk to national security, or (iii) there is a change in ownership, change to entity structure, or other substantial change in the circumstances of the small business concern that DOE could determine poses a risk to national security.

(15 U.S.C. § 638(g), (o)).

Signature ___________________________________________________________

Date

Print Name (First, Middle, Last)

Role/Title

Name of Small Business Concern

The Disclosure of Foreign Relationships is a part DOE's due diligence program under 15 U.S.C. § 638(vv) and is exempt from the Paperwork Reduction Act.