NSFF NOFO Attachment V Individual Legal Questionnaire.xlsx
XLSX spreadsheet 74 KB Posted
- Attached to
- National Security Fund Finance (“NSFF”) Program
- Solicitation number
- WHSAD0819
- Issued by
-
DOD Washington Headquarters Service
About this file
This file is an Individual Legal Questionnaire template required for submission with the National Security Fund Finance (NSFF) Program funding application. The questionnaire must be completed for each principal associated with an applicant seeking financing under this OSC program, which provides loans to qualified investment fund managers for critical minerals and materials supply chains vital to U.S. national security.
The questionnaire requires disclosure of criminal history, civil litigation, regulatory investigations, and financial delinquencies spanning various timeframes. Applicants must answer 20 detailed questions addressing: criminal charges or convictions (excluding minor motor vehicle violations); civil liability or settlements involving fraud or breach of trust; investigations or disciplinary proceedings by governmental or regulatory bodies; suspension, debarment, or enforcement actions; securities law violations; civil litigation exceeding specified thresholds ($500,000 for corporate liabilities; $100,000 for personal liabilities); shareholder litigation or fiduciary duty breaches; bankruptcy filings within the past 10 years; and failure to pay federal or state obligations. The questionnaire defines "substantial ownership interest" as 20% or more in equity, voting, or profit interests, and "senior management" as meaningful participation in budget or investment decisions, including board membership. Respondents must provide complete details for affirmative answers, including names, dates, locations, docket numbers, fines, sentences, and relevant documents. The form requires certification that all information is true and complete, with acknowledgment that false statements constitute federal crimes punishable by up to $1 million in fines and 30 years imprisonment, along with potential debarment or suspension from federal programs.
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| File | Type | Posted |
|---|---|---|
| NSFF NOFO_Attachment IV Investment Track Record.xlsx | XLSX spreadsheet | |
| NSFF NOFO.pdf |
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Individual Legal Questionnnaire
| Individual Legal Questionnaire | OMB Approval No. [XXXXX] | ||||
| As of Date: | MM/DD/YYYY | Expiration Date [XX/XX/XXXX] | |||
| You are required to submit this exhibit for each principal. Answer all of the following questions. If the answer to any question is “yes”, furnish complete details and provide any necessary attachments. Include all pertinent information, including, name(s) under which charged, dates, locations, titles of proceedings, docket numbers, fines and penalties (paid and unpaid), sentences, type of offense (misdemeanor or felony), dates of parole/probation, names of mediators, arbitrators or other alternative dispute resolution professionals, and relevant documents. For the purposes of this exhibit, a “substantial ownership interest” in an organization is considered to be an interest, direct or indirect, of 20% or more in equity interests, voting interests, or profit interests. The term “senior management” generally refers to meaningful participation in budget or investment decisions, including participation as a member of the board of directors. If you have questions about whether or not you would have been considered part of senior management, discuss the issue with the Office of Strategic Capital. This exhibit must be signed when submitted as part of an NSFF funding application. | |||||
| Name of Applicant: | Name of Principal: | [First] | [Last] |
1 Have you ever been charged with or arrested for any criminal offense other than a minor motor vehicle violation (including offenses that have been dismissed, discharged, expunged, or not prosecuted or settled through plea deal or other similar process)?
2 Have you ever been convicted, placed on pretrial diversion, entered into a plea deal or other similar process, or placed on any form of probation (including adjudication withheld pending probation) for any criminal offense other than a minor motor vehicle violation?
3 Have you ever ever (a) been found civilly liable, (b) entered into a settlement through mediation, arbitration or other alternative dispute resolution process or (c) been permanently or temporarily enjoined by a court or other regulatory body by reason of any act or practice involving fraud or breach of trust?
4 Has any organization either while you were a member of senior management or when you had a substantial ownership interest, ever been indicted for, charged with, entered into a plea deal for, or convicted of any criminal offense involving fraud, breach of fiduciary duty or breach of trust?
5 Has any organization, either while you were a member of senior management or when you had a substantial ownership interest, ever been found liable, convicted or permanently or temporarily enjoined by a court, or entered into a settlement agreement by mediation, arbitration or other alternative dispute resolution process by reason of any act or practice involving fraud, breach of fiduciary duty or breach of trust?
6 Are you now the subject of any investigation or disciplinary hearing or proceeding by a governmental agency, regulatory body, or professional association?
7 Have you ever been the subject of any investigation or disciplinary hearing or proceeding by a governmental agency, regulatory body, or professional association?
8 Are you now or have you ever been the subject of any suspension, debarment, or any other regulatory enforcement, or any other regulatory enforcement action by a State or Federal agency based on fraud, lack of business integrity, or violation or noncompliance with regulations or other governmental requirements?
9 Has any organization, either while you were a member of senior management or when you had a substantial ownership interest, ever been the subject of any investigation or disciplinary hearing or proceeding by a governmental agency, regulatory body, or professional association?
10 Is any organization of which you are currently a member of senior management, or in which you have a substantial ownership interest, now the subject of any investigation or disciplinary proceeding by a governmental agency, regulatory body, or professional association?
11 Have you ever entered into an agreement through mediation, arbitration, other alternative dispute resolution process or similar process, or otherwise consented to any order or decree by a court, governmental agency or regulatory body in connection with any federal or state securities law?
12 Has any organization, either while you were a member of senior management or when you had a substantial ownership interest, ever entered into an agreement through mediation, arbitration, other alternative dispute resolution process or similar process, or otherwise consented to any order or decree by a court, governmental agency or regulatory body in connection with any federal or state securities law?
13 During the past 10 years, have you been a named defendant in any civil legal action involving commercial disputes or creditor's claims (including but not limited to debt collection lawsuit, foreclosure, receivership, and involuntary liquidation) of greater than $500,000 for corporate liabilities or greater than $100,000 for personal liabilities?
| If “yes”, did the subject matter involve your personal conduct or fall within your area of responsibility? |
| If the answer is “yes”, were you active in settlement negotiations or arbitration? |
14 Have you, as a result of your role as a member of senior management or as a member of the board of directors of any entity been a named defendant in any civil legal action involving (i) shareholder litigation, (ii) fraud or misrepresentation, or (iii) breach of fiduciary duty?
| If “yes”, did the subject matter involve your personal conduct or fall within your area of responsibility? |
| If the answer is “yes”, were you active in settlement negotiations or arbitration? |
15 Have you or has any entity Associate (within the meaning of 13 C.F.R. § 107.50) of the Applicant ever been a party to any litigation or other proceeding involving allegations of criminal conduct, violation of professional standards, fraud, breach of fiduciary duty, willful misconduct, or unfair business practices attributable in any manner to your position or alleged conduct, acts, or omissions or, to your knowledge, those of any person required to be identified in item 9 of the Form 2181, Exhibit B?
16 Have you, in your individual capacity, ever been a named defendant in any civil legal action involving (i) shareholder litigation, (ii) fraud or misrepresentation, or (iii) breach of fiduciary duty?
17 During the past 10 years, have you filed voluntarily, or had filed against you involuntarily, a bankruptcy petition?
18 During the past 10 years, has any organization, either while you were a member of senior management or when you had a substantial ownership interest, filed voluntarily, or had filed against such organization involuntarily, a bankruptcy petition?
19 Have you ever failed to pay when due any debt or obligation, including any amounts in dispute, to the Federal government or any state government, or guaranteed by the Federal government or any state government (including but not limited to taxes, business loans, student loans, etc.)?
20 Has any organization, either while you were a member of senior management or when you had a substantial ownership interest, ever failed to pay when due any debt or obligation, including any amounts in dispute, to the Federal government or any state government, or guaranteed by the Federal government or any state government (including but not limited to taxes, business loans, educational loans, etc.)?
| CERTIFICATION AND AUTHORIZATION TO RELEASE INFORMATION |
| I certify that all of the information I have provided on this Individual Legal Questionnaire and any other information I have submitted in connection with this Individual Legal Questionnaire is true, correct and complete to the best of my knowledge. I understand that knowingly making a false statement is a violation of Federal law and could result in criminal prosecution under 18 USC §§ 287, 371, 1001, 1006, and 1014, including fines of up to $1 million and up to 30 years imprisonment, 15 USC §§ 645 and 687(f), civil penalties under 31 U.S.C. § 3729, and government-wide debarment or suspension. |
| In connection with an application for NSFF funding, I hereby authorize the Office of Strategic Capital and its agents to make inquiries, including obtaining a consumer report from a consumer reporting agency, to determine by person credit standing. |
| I authorize the Office of Strategic Capital to request criminal record information about me from criminal justice agencies for the purpose of determining my eligibility for the NSFF funding program. |
20 Printed Name
21 Title
22 Signature
23 Date
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