Attachment_09_DLA_Form_1822.docx

IFB/CONTRACT/OFFER/SF123 ORDER NO.

The public reporting burden for this collection of infom1atlon is estimated to average 20 minutes per response, lnduding the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, induding suggestions for reducing this burden, to the Department of Defense, Washington Headquarters Services, Executive Services Directorate, Information Management Division, 4800 Mark Center Drive, East Tower, Suite 02G09, Alexandria, VA 22350-3100 (0704-0382). Respondents should be aware that notwithstanding any other provision of law, no person shall be su_bject to any penalty for failing to comply with a collection of Information if ii oes not display a curren y valid 0MB control number. RETURN COMPLETED FORM TO THE OFFICE STATED ON THE IFB, SOLICITATION OR PROPOSAL.

INSTRUCTIONS. This form must be fully completed by ell applicants for United States Munitions List items (USML)IO,mmerce Control Us/ //ems (CCU) prior to acceplance by the U.S. Government and conslilutes an integral part of this bid. The information given must be true and coffect and will become a parl of this contract. Every block MUST have an entry. If necessal)I, lnsen 'NONE "SAME AS BLOCK X • or 'NOT APPLICABLE" (do no/ use 'NIA'). If the applicant Is acb·ng solely as an Agent, a DLA Form 1822 must be signed by the Principal. The term Approving Official is used to Indicate the person authorized to act for the U.S. Government (Sales 0,ntrac/ing Officer Plant Clearance Officer or other designated ind"Nidual). FOR ALL SALES OF PROPERTY APPROVED BY Pt.ANT CLEARANCE OFFICERS UPON THE REMOVAL OF THE PROPERTY, ALL DOCUMENTATION REQUIRED BY THIS FORM \,vl'LL BE FORWARDED TO THE IDENTIFIED TRADE SECURITY CONTROL OFFICE, The following applies to all properly subject of sale using lhis form: the use, disposition, exporl, or re-fixporl of this properly, is subject to the publications, penalties, and other provisions of the economic programs administered by the Office of Foreign Assets Control, U.S. Treasury Department, 31 CFR Chapter V.

Att ac hm e nt 9

SP45

0-19-R-00 J a pan Sc ra p

DATE OF BtRTH (MMIDDNYI)

PLACE OF BIRTH (City or County, Slate, Counl,y) 1 TELEPHONE NUMBER (Include Area Code)

MAILING ADDRESS PHYSICAL ADDRESS

SECTION I. GENERAL INFORMATION

APPLICABILITY. This statement applies to the property for which we have submitted our bid/offer pursuant to the above idenlified invita/ion.

1. TYPE OF FIRM

0 SOLE PROPREITORSHIP

PARTNERSHIP 0

CORPORATION

OTHER (Specify)

2. NATURE OF END-USER'S BUSINESS 3. NATURE OF PRINCIPAL'S BUSINESS 4. FIRM'S IDJFEDERAL TAX NUMBER

B. ADDRESS (Physical location) B. ADDRESS (Physical location)

7. ALL CORPORATE OFFICERS, PARTNERS AND/OR AGENTS ARE TO PROVIDE, ON SEPARATE SHEETS OF PAPER, THEIR NAMES, ADDRESSES, SSNs, DATES AND PLACES OF BIRTH. FAILURE TO PROVIDE THIS INFORMATION COULD RESULT IN SIGNIFICANT DELAY OR DENIAL OF THE AWARD. (See attached) SECTION II. END USE/USER INFORMATION. If !his is a negotiated exchange, identify the property being exchanged:

1. PURPOSE. THE PROPERTY REFERRED TO IN ABOVE IFB/OFFER NUMBER WILL BE UTILIZED FOR THE FOLLOWING: Enter and 'X' in the appropriate item(s) below. In the case of resale, Item 1.F. or 1.G. MUST be marked.

or to non-U.S. Citizens/Nationals in the United States.

and distribution in (Country/Countries):

LJ G. The customers are unknown at this time. If required by the contract/transfer document, I will obtain prior written approval for the resale of any of the property covered by this contract.

ADDITIONAL INFORMATION: State any other material facts relating to end user and use of the property which may be of value in considering the proposal:

NOTE: Example of specific uses: AIRCRAFT. The bidder/recipient certifies that the aircraft will be used: as a flyable aircraft; as a nonflyable aircraft to be used only for parts, display, or ground instruction, etc.; for resale as a flyable aircraft DLA FORM 1822, JAN 2013 ALL OTHER VERSIONS ARE OBSOLETE Page 1 of2 PDF {DLA)

SECTION Ill. UNDERSTANDING AND NOTIFICATIONS

1 . The use, disposition, export and re-export of lhis property is subjecl to all applicable U.S. Laws and Regulations, Including bul nol limited to the Arms Export Control Act (22 USC 2751 el seq.); Export Administration Act of 1979 (50 USC App.2401 et seq.) as continued under Executive Order 12924; International Traffic in Arms Regulations (22 CFR 120 et seq,); Export Administration Regulations (15 CFR 730 et seq,); Foreign Assets Control Regulations (31 CFR 500 et seq.) and the Espionage Act {18 USC 793 et seq.); which, among other things, prohibit:

A. The making of false statements and concealment of any material information regarding !he use or disposition, export or re-export of !he property and B. Any use, disposition, export or re-export of lhe property not permitted by applicable statule and regulation.

2. The submission of false or misleading Information and/or concealment of any material facts regarding the use, disposition or export of this property may constitute a violation of provisions of 18 USC 793/1001, 22 USC 2778/2779, 50 USC App. 2410, and 50 USC App. 1-44. Sanctions for violations will be in conformilywith U.S. laws and regulations (lncludlng Federal Acquisition Regulations and DoDD 2030.8) and may include the denial of U.S. export privileges and of any participation in fulure U.S. Government contracts,

3. Transfers of USML and CCLI property by purchasers/bidders are subject to the requirements of the appropriate licensing departmenl or agency. In many cases, an export license or other authorization may be required. Wth respect to USML, registration of lhe purchaser's/bidder's business with the Department of the State may also be required. It Is the responsibility of lhe purchaser/bidder to determine what the applicable requirements may be and to obtain all necessary authorization or approvals.

4.1/-Jhen USMUCCU property is lfansferred, the Information In this form regarding the above laws and regulatlons must be passed lo the subsequent purchaser/receiver. Records of Resale in buyer's possession should be available for Trade Security Controls Office review, if requested.

5. The Invitation For Bid and Sale/Exchange Contract number can be referenced when submitling an application for an export license or other authorization to the Department of Slate for USML or Department of Commerce for CCLI.

6. The Government expects the Purchaser/Recipient to cooperate with all authorized Government representatives to verify the existence and condition ofUSMUCCLI, SECTION IV. CERTIFICATION STATEMENT TO BE SIGNED BY BIDDER AT TIME OF RESPONSE TO IFB

1 . I do certify that afl Information given In this Statement Regarding Disposition and Use of Property is true and correct to the best of my knowledge and belief and have not knowingly omitted any information which Is Inconsistent with this statement. I understand this statement will be referred to and be a part of the contract of sale/exchange with the U.S; Government. I agree to submit a written request for amendment of this statement to the Approving Official prior to effecting any change of fact or Intention from that slated herein or in any prior amendment, whether occurring before or after the release of the commodities, and not to effect such changes without first receiving written approval of the Approving Official.

2. I acknowledge having been advised that the USMUCCLI property I purchased Is controlled by the U.S. Government and In many cases cannot be transferred (exported, sold or given) to a foreign country, a non-U.S. Citizen/National or a non-Permanent US Resident without a valid State/Commerce Department export authorization. Should I transfer this property to a foreign country, a non-U.S. Citizen/National or a non-Permanent US Resldenl, I will obtain any required authorization before making such transfers, I will not transfer this property to countries, regimes and nationals targeted under the sanclfons program administered by the U.S. Treasury Department's Office of Foreign Assets Control.

3. Neither the applicanl, corporate officers, directors or partners is:

A. The subject of an indictment for or has been convicted of violaling any or the U.S. Criminal statutes enumerated in 22 CFR 120.27 since the effective date of lhe Arms Export Control Act, Public law 94-329, 90 Stat. 729 (June 30, 1976) ; or

8. Ineligible to contract with, or to receive, a license or other approval from any agency of the U.S. Government.

4. The person signing this DLA Form 1822 ls:

· a Citizen of the United States of America, or

· lawfully admitted to the United Stales for Permanent Residence and maintains such residence under the lmmigralion and Nationality Act, as amended (8 USC 1101 (a), 20, 60 Slat. 163), or □D a Citizen ot , and/or Is an official of a foreign government entity in the United States.

PRIVACY ACT STATEMENT

AuthOrlty: 10 U.S.C. 133, Under Seaeteiy of Defenso for Acquisition, Te¢Mok>gy, and l0gi,tics; 22 U.S.C. 2761-2799, Arms Export Control; 50 App. U.S.C. 2401 et seq., ExpooAdministratioo; E.O. 12738 and E.O. 12981, Export Controls; 22 CFR 122, 15 CFR 762, 41 CfR 101 and 102; DoD Dire<:tive 2040.3, End Use Certificates (EUCS); DoD lr»truclioo 2030.08, lmplementatio<l or Trade Security Controls (TSC) for Transrers of DoD U.S. MLJ<ljtions Lisi (USML) and Com:nerce Control List (CCL) Persooal Property to Parties Outside DoD Control; DoO lnstroctioo 2040.02, lnl emational Trsnsrers of Technology, Artides, and Seiv.ces; DoD lnslluction 4161,2, Managemenl, Control and Disposal of Government Ptoperty In the Possesslon of Contractors; DoD 4160.21-M, Deroose Materiel Disposition Manual; DoD Manual 4160.28, Defense Demlnatization and E.0 . 9397 (SSN), as amero ed.

Purpo se: lnfomiation Is use<I to <letermlna bidder et;gib:foty to participate ill the ptog(ams and to ensure !hat property redp!ents oomply with the terms of the sale regru-dillg end use of the p,operfy.

Routine uses: Data may be disclosed to the Depa,tment or Transportation lo ensure comptiaoce v.ith ru!es regar<f,ng Federal Aviation AdministraHon a!rworth!Mss certificates for surplus military a!ra aft to the General Seri.cas AdmWstration to determ!'1o lhe p,eseoce ol debarment procMdings aga:nst a bidder, 10 the Department or State to ensure compliance with lhe International Traffic In Alms reg\laUons; to the Department or Commerce to ensure compfiance with lhe Export Adm!nlstrafon reg\latioos; and to the Department or JtJstice for asset identification. location and rOOJvery; and for immigration and naturalization data verification. Data may also be p,ov'.ded under the DoD 'Blanket Routine Uses· publlshed al http://dpclo.defensa.gov/prtvacy/SORNslbla nl<e t_routine_uses.hllri.

Disclosure: Voluntary; however, failtJre to p,o;1de the requested lnfomiation may result In lll eligb l ily to receive surplus or fore:gn personal propetty.

Rules of use: Rules for collecting, using, retaining, and safeguard:ng this information a,e contained in DLA Piivac'j Act system of rOOJrds notice 5640.45, entitled "End Use Certificates• avaiJable at http:/Jdpdo.delense.gov/privacy/SORNs/componenV<lla/S640.45.html

DLA FORM 1822, JAN 2013 ALL OTHER VERSIONS ARE OBSOLETE Page 2 of 2 PDF (DLA)