DS-4100 Iran Program Grants

U.S. Department of State

IRAN PROGRAM GRANTS

OMB APPROVAL NO.1405-0176
EXPIRATION DATE: 06-30-2007
ESTIMATED BURDEN: 1HOUR

Bureau of Near Eastern Affairs (NEA)
Bureau of Democracy, Human Rights and Labor(DRL)
Bureau of Educational and Cultural Affairs (ECA)
Name of Organization

Address of Organization

Grant Title

Title of The Position

Name (Last, First, MI.)

Date of Birth
(mm-dd-yyyy)

Place of Birth

Nationality

President
Treasurer
Board of Directors
Board of Directors
Board of Directors
Board of Directors
Program Director
Program Assistant(s)
Program Assistant(s)
Contractors/Sub Grantees
Contractors/Sub Grantees
Contractors/Sub Grantees
Contractors/Sub Grantees

PRIVACY ACT STATEMENT
The information collected is solicited to assist the U.S. Department of State to effectuate the goals of sections 481(b), 531(a), 571, 582, and 635(b) of
the Foreign Assistance Act of 1961 (as amended); 18 U.S.C. § 2339A and 2339B; Executive Order 13224; and Homeland Security Presidential
Directive 6. The information collected will be used to ensure that the Department of State complies with relevant laws and regulations designed to
prevent U.S. persons and funds from supporting terrorists or terrorist activity. The information collected may be released to federal, state, or local
agencies in the United States, or foreign agencies, for the purpose of considering the relevant grant or sub-grant application(s), or for law enforcement,
counter-terrorism, or homeland security purposes; to the United States Congress and U.S.courts within their sphere of jurisdiction; and to other federal
agencies for certain personnel and records management matters. Failure to provide the requested information may result in the denial of your
application for a grant or contract.
PAPERWORK REDUCTION ACT STATEMENT
Public reporting burden for this collection of information is estimated to average one hour 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. Department of State, A/ISS/DIR, 1800 G St. NW, Washington, DC
20520
DS-4100
03-2007