Statement of Affiliation Non-Disclosure.pdf

STATEMENT OF AFFILIATION

For the purpose of this form, a foreign interest is defined as any of the following:

1. A foreign government or foreign government agency;

2. Any form of business enterprise or legal entity organized, chartered or incorporated under the laws of any country other than the United States or its possessions;

3. Any individual who is not a U.S. citizen; or

4. Any form of business enterprise organized or incorporated under the laws of the U.S., or a State or other jurisdiction within the U.S. that is owned, controlled or influenced by one of the entities described in 1, 2 or 3, above.

1. (Answer 1a. and 1b.)

a) (For entities which issue stock) Foreign interest do not own, or have beneficial ownership in

5% or more of my organization’s equity securities. ☐ I acknowledge

b) (For entities which do not issue stock) Foreign interest have not subscribed 5% or more of my organization’s total capital commitment. ☐ I certify as accurate.

2. My organization, directly and indirectly through subsidiaries and affiliated, does not own 10% or more of any foreign interest. ☐ I certify as accurate.

3. Foreign interest do not serve as members on my organization’s board of directors (or similar governing body), or as officers, executive personnel, general partners, regents, trustees or senior management officials. ☐ I certify as accurate.

4. Foreign interest do not have the power, direct or indirect, to control the election, appointment, or tenure of members of your organization’s board of directors (or similar governing body) or other management positions of my organization, or have the power to control or influence other decisions or activities of my organization.

☐ I certify as accurate.

5. My organization does not have any contracts, agreements, understandings or arrangements with a foreign interest(s) that cumulatively represent 10% or more of my organization’s annual gross income. ☐ I certify as accurate.

6. My organization, whether as borrower, surety, and guarantor or otherwise, does not have any indebtedness, liabilities or obligations to a foreign interest.

☐ I certify as accurate to the best of my knowledge or through my best efforts.

7. If my organization divided last fiscal year, neither of the following applied.

a. 5% or more of total revenues or net income was not from any single foreign interest.

b. In the aggregate, 30% or more of total revenues or net income was not from foreign interest.

☐ I certify as accurate to the best of my knowledge or thorough my best efforts.

8. Less than 10% of any class of my organization’s voting securities is held in “nominee” shares, in

“street names” or by some other method that does not identify the beneficial owner. ☐ I certify as accurate.

9. No members of my organization’s board of director (or similar governing body), or officers, executive personnel, general partners, regents, trustees or senior management officials of my organization hold any positions with, or serve as consultants for, any foreign interest. ☐ I certify as accurate.

10. There are no other factors that indicates or demonstrates a capability of a foreign interest to control or influence the operations or management of my organization.

☐ I certify as accurate.

Failure to respond to any of the above questions will deem the prime contractor as having a Foreign interest.

By signing below, the undersigned does hereby agree that the information contained in this document is accurate and complete at the time of submission.

Print Name: ___________________________________________________________ __

Signature and Date: Title:

(Must be signed by a senior official of the company)