Attachment_10_DS_4184.pdf

Is this work performed for Syria?

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 4: CERTIFICATION

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

Request Number

PART 5: SUBMISSION DETAILS (GOVERNMENT USE ONLY)

Request Initiator

Project Name Date Received (mm-dd-yyyy)

DS-4184

02-2016

PART 2: AFGHANISTAN

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

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

Phone Number Cell Phone Number Fax 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)

Purpose of Contract/Grant

U.S. Department of State

RISK ANALYSIS INFORMATION

OMB APPROVAL NO. 1405-0204

EXPIRES: 2/28/2019

ESTIMATED BURDEN: 80 Minutes*

Solicitation Number

Contract Grant Other

PART 3: SYRIA

Yes No

Signature Date (mm-dd-yyyy)

(User Name)

SAQMMA16R0106 - Diplomatic Platform Support Services (DiPSS) Attachment 10- DS Form 4184

Location of Previous Unit (Province, City/Municipality/Town, neighborhood, facility and station, Country)

Description of Duties in Opposition Organization Date Joined Opposition (mm-dd-yyyy)

Country of Issuance

Page 2 of 8DS-4184

KEY INDIVIDUAL INFORMATION

Name (Last, First, MI) Other Names Used ("Also known as", nicknames, alias, different spelling)

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

Male Female

Citizenship(s)

Address Phone Number Cell Phone Number

Skype Address E-mail Address

Current Employer

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

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

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

Organizational Title Project Title

Father's Name Tribe

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

Tazkera Number Passport Number

Location of Current Unit (Province, City/Municipality/Town, neighborhood, facility and station, Country)

Previous Profession (for those who never served in the Syrian government, aside from compulsory military service)

Work Performed for AMOS (If answered Yes in Section 3)

Time Served (mm/yyyy to mm/yyyy)

Previous Syrian Arab Republic Government (SARG) Ministry and Unit

Previous Position (Rank/Title)

Description of Duties

Additional Information Required for Defected Regime Personnel Only:

to

Unit #

Location of Previous Unit (Province, City/Municipality/Town, neighborhood, facility and station, Country)

Country of Issuance

Page 3 of 8DS-4184

KEY INDIVIDUAL INFORMATION

Name (Last, First, MI) Other Names Used ("Also known as", nicknames, alias, different spelling)

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

Male Female

Citizenship(s)

Address Phone Number Cell Phone Number

Skype Address E-mail Address

Current Employer

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

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

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

Organizational Title Project Title

Father's Name Tribe

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

Tazkera Number Passport Number

Location of Current Unit (Province, City/Municipality/Town, neighborhood, facility and station, Country)

Previous Profession (for those who never served in the Syrian government, aside from compulsory military service)

Work Performed for AMOS (If answered Yes in Section 3)

Time Served (mm/yyyy to mm/yyyy)

Previous Syrian Arab Republic Government (SARG) Ministry and Unit

Previous Position (Rank/Title)

Description of Duties

Additional Information Required for Defected Regime Personnel Only:

to

Unit #

Location of Previous Unit (Province, City/Municipality/Town, neighborhood, facility and station, Country)

Country of Issuance

Page 4 of 8DS-4184

KEY INDIVIDUAL INFORMATION

Name (Last, First, MI) Other Names Used ("Also known as", nicknames, alias, different spelling)

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

Male Female

Citizenship(s)

Address Phone Number Cell Phone Number

Skype Address E-mail Address

Current Employer

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

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

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

Organizational Title Project Title

Father's Name Tribe

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

Tazkera Number Passport Number

Location of Current Unit (Province, City/Municipality/Town, neighborhood, facility and station, Country)

Previous Profession (for those who never served in the Syrian government, aside from compulsory military service)

Work Performed for AMOS (If answered Yes in Section 3)

Time Served (mm/yyyy to mm/yyyy)

Previous Syrian Arab Republic Government (SARG) Ministry and Unit

Previous Position (Rank/Title)

Description of Duties

Additional Information Required for Defected Regime Personnel Only:

to

Unit #

Location of Previous Unit (Province, City/Municipality/Town, neighborhood, facility and station, Country)

Country of Issuance

Page 5 of 8DS-4184

KEY INDIVIDUAL INFORMATION

Name (Last, First, MI) Other Names Used ("Also known as", nicknames, alias, different spelling)

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

Male Female

Citizenship(s)

Address Phone Number Cell Phone Number

Skype Address E-mail Address

Current Employer

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

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

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

Organizational Title Project Title

Father's Name Tribe

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

Tazkera Number Passport Number

Location of Current Unit (Province, City/Municipality/Town, neighborhood, facility and station, Country)

Previous Profession (for those who never served in the Syrian government, aside from compulsory military service)

Work Performed for AMOS (If answered Yes in Section 3)

Time Served (mm/yyyy to mm/yyyy)

Previous Syrian Arab Republic Government (SARG) Ministry and Unit

Previous Position (Rank/Title)

Description of Duties

Additional Information Required for Defected Regime Personnel Only:

to

Unit #

Location of Previous Unit (Province, City/Municipality/Town, neighborhood, facility and station, Country)

Country of Issuance

Page 6 of 8DS-4184

KEY INDIVIDUAL INFORMATION

Name (Last, First, MI) Other Names Used ("Also known as", nicknames, alias, different spelling)

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

Male Female

Citizenship(s)

Address Phone Number Cell Phone Number

Skype Address E-mail Address

Current Employer

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

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

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

Organizational Title Project Title

Father's Name Tribe

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

Tazkera Number Passport Number

Location of Current Unit (Province, City/Municipality/Town, neighborhood, facility and station, Country)

Previous Profession (for those who never served in the Syrian government, aside from compulsory military service)

Work Performed for AMOS (If answered Yes in Section 3)

Time Served (mm/yyyy to mm/yyyy)

Previous Syrian Arab Republic Government (SARG) Ministry and Unit

Previous Position (Rank/Title)

Description of Duties

Additional Information Required for Defected Regime Personnel Only:

to

Unit #

Location of Previous Unit (Province, City/Municipality/Town, neighborhood, facility and station, Country)

Country of Issuance

Page 7 of 8DS-4184

KEY INDIVIDUAL INFORMATION

Name (Last, First, MI) Other Names Used ("Also known as", nicknames, alias, different spelling)

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

Male Female

Citizenship(s)

Address Phone Number Cell Phone Number

Skype Address E-mail Address

Current Employer

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

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

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

Organizational Title Project Title

Father's Name Tribe

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

Tazkera Number Passport Number

Location of Current Unit (Province, City/Municipality/Town, neighborhood, facility and station, Country)

Previous Profession (for those who never served in the Syrian government, aside from compulsory military service)

Work Performed for AMOS (If answered Yes in Section 3)

Time Served (mm/yyyy to mm/yyyy)

Previous Syrian Arab Republic Government (SARG) Ministry and Unit

Previous Position (Rank/Title)

Description of Duties

Additional Information Required for Defected Regime Personnel Only:

to

Unit #

PAPERWORK REDUCTION ACT STATEMENT

*Public reporting burden for this collection of information is estimated to average 80 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 559 of the Appropriations Act, Executive Orders 13224, 13099, and 12947, and Homeland Security Presidential Directive 6.

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) for collaborative and vetting programs.

Disclosure: Disclosure of the information provided on this form will be done in accordance with the Department of State's System of Records Notice concerning the Risk Analysis and Management System (RAM) (enter SORN #) which establishes the routine uses and Privacy Act exceptions which apply to this system.

Appendix Key Personnel (Use continuation sheets, as necessary)

Key personnel may include but is 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.

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).

INSTRUCTIONS