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).
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