Attachment_J.1._USAID_Information_Form.docx
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- Attached to
- Health Sector Resiliency Project Federal contract opportunity
- Solicitation number
- SOL-306-14-000086
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Attachment J.1 USAID Information Form .
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J.1 USAID Information Form
Part I: Information About Proposed Activities (all parts mandatory)
1. Name of the proposed awardee of USAID contract or assistance (Firms must include a copy of applicable licenses to do business in Afghanistan)
2. Type of proposed award or other assistance (check one):
|_| Contract or Subcontract |_| Grant or Subgrant |_| Training |_| Equipment |_| Other
3. US$ amount and estimated start/end date of proposed award or assistance:
Dollar amount: $ Start: End:
4. Purpose of proposed award or assistance:
5. Organization proposed to receive award or other assistance:
| a. Name: |
| b. JCCS Registration # (Optional) |
c. Address:
| d. Telephone: |
| e. Fax: |
| f. Email: |
g. Tribal affiliation or clan
6. Information on Key Individuals associated with the organization named in 5 above, or, if no organization is listed, information on each individual to receive cash or in-kind assistance (including technical assistance). Use continuation sheets as necessary.
** = mandatory information.
| A. Name (As in passport or other government-issued photo ID):** |
| Government-issued photo ID number, type of ID and country of issuance:** |
| Place of birth:** |
| Date of birth:** (mm/dd/yyyy) |
| Rank or title in organization listed in #5 (if “key individual”):** |
Other names used (may include nicknames, pseudonyms not listed under “Name”):**
Gender:**
Current employer and job title:
Occupation:
Address of residence:**
Citizenship(s):** (Afghans: Tribal affiliations and Father’s Name)
Email:
Part II: Contractor/Grantee/Recipient Certification:
Potential Awardee certifies in submitting this form that it has taken reasonable steps (in accordance with sound business practices) to verify the information contained in this form. Contractor/Grantee/Recipient understands that the US Government may rely on the accuracy of such information in processing this vetting request.
| Name: |
| Signature: |
| Title/Organization: |
| Date: |
Part III: Submission details (to be completed by USG vetting official)
Vetting request number
Staff member who initiated request
Project name
Date submitted for screening
(Use additional continuation sheets as necessary):
| B. Name (As in passport or other government-issued photo ID):** |
| Government-issued photo ID number, type of ID and country of issuance:** |
| Place of birth:** |
| Date of birth:** (mm/dd/yyyy) |
| Rank or title in organization listed in #5 (if “key individual”):** |
Other names used (may include nicknames, pseudonyms not listed under “Name”):**
Gender:**
Current employer and job title:**
Occupation:
Address of residence:**
Citizenship(s):** (Afghans: Tribal affiliations and Father’s Name)
Email:
| C. Name (As in passport or other government-issued photo ID):** |
| Government-issued photo ID number, type of ID and country of issuance:** |
| Place of birth:** |
| Date of birth:** (mm/dd/yyyy) |
| Rank or title in organization listed in #5 (if “key individual”):** |
Other names used (may include nicknames, pseudonyms not listed under “Name”):**
Gender:**
Current employer and job title:**
Occupation:
Address of residence:**
Citizenship(s):** (Afghans: Tribal affiliations and Father’s Name)
Email:
| D. Name (As in passport or other government-issued photo ID):** |
| Government-issued photo ID number, type of ID and country of issuance:** |
| Place of birth:** |
| Date of birth:** (mm/dd/yyyy) |
| Rank or title in organization listed in #5 (if “key individual”):** |
Other names used (may include nicknames, pseudonyms not listed under “Name”):**
Gender:**
Current employer and job title:
Occupation:
Address of residence:**
Citizenship(s):** (Afghans: Tribal affiliations and Father’s Name)
Email:
| E. Name (As in passport or other government-issued photo ID):** |
| Government-issued photo ID number, type of ID and country of issuance:** |
| Place of birth:** |
| Date of birth:** (mm/dd/yyyy) |
| Rank or title in organization listed in #5 (if “key individual”):** |
Other names used (may include nicknames, pseudonyms not listed under “Name”):**
Gender:**
Current employer and job title:
Occupation:
Address of residence:**
Citizenship(s):** (Afghans: Tribal affiliations and Father’s Name)
Email:
INFORMATION FORM INSTRUCTIONS
Please provide information for key individuals of all organizations receiving funds from USAID, including grantees, sub-grantees, Contractors, and vendors, who work in Afghanistan. Please do not provide information for United States citizens or permanent legal residents of the United States.
Part I
Question 1 – Self-explanatory Question 2- Indicate the proposed type of mechanism to be utilized by placing a check mark on the line in front of the appropriate term Question 3 – Enter the amount of award or assistance in US dollars and indicate the start and end date of the program using a mm/dd/yyyy format Question 4 – Indicate the purpose of the award or assistance. Use additional sheets and attach to page one of the vetting form if necessary Question 5 a-g – Self-explanatory.
Attach a copy of the relevant Afghan business license.
Question 6 - “Key Individual” means (i) Any large shareholder: defined as owning 10% or more of an equity stake in the organization, whether publically or privately held; (ii) Principal officers of the organization's governing body (e.g., chairman, vice chairman, treasurer or secretary of the board of directors or board of trustees); (iii) The principal officer and deputy principal officer of the organization (e.g., executive director, deputy director; president, vice president); (iv) The program manager or chief of party for the USAID-financed program; and (v) Any other person with significant responsibilities for administration of USAID financed activities or resources (while a comprehensive list is not possible, this would include any person acting in a role substantially similar to those outlined in (i)-(iv). For Private Security Companies, this would include leadership roles down to the level of field commanders). Complete for each of these four categories or indicate “N/A” if a category does not apply. Use additional pages as needed. Attach copies of photo ID for each “key individual”.
Note: If a “Key Individual” is a US Citizen or Permanent Resident, no information is required.
Part II Individual filling out form must read the Certification and print their name where indicated, sign where indicated, print their title and the name of their organization where indicated, and print the date where indicated.
Part III
This section is not for individual’s information and will be completed by the USG vetting official.
File details come from the government source that posted it. Updated .