Form DOE-F-580.1 U.S. Department of Energy End-Use Certificate

DOE F 580.1
(Rev Date 05/03)

OMB Control Number 1910-5121

U.S. DEPARTMENT OF ENERGY
END-USE CERTIFICATE
STATEMENT REQUIRED FOR OBTAINING
High-Risk PROPERTY BEING RELEASED
FROM U.S. DEPARTMENT OF ENERGY
(DOE) CONTROL

(Please read Privacy Act Statement
before completing this form. If additional
space is required, use separate sheets
and identify by Block Number)

AGENCY APPROVAL FOR
SALE/TRANSFER OF NSG
TRIGGER LIST/ DUAL USE ITEMS
OR U.S. MUNITIONS LIST ITEMS:

Sale/Transfer Document Control Number

Administrator, National Nuclear Security
Administration (NA-1)

TYPE OR PRINT ALL INFORMATION

Privacy Act Statement
Authority:
10 USC 136; 40USC 471; 50 USC 2411; 22 USC 2751; and EO 9397.
Principal Purpose(s): Determine applicant eligibility to participate in the DOE sales and/or non-Federal transfer
programs and ensure that property recipients comply with the terms of the sale or transfer.
Routine Uses:
Data may be disclosed to Department of State, Commerce, Treasury, Transportation, and
Justice for determining compliance with applicable laws and regulations and to the General
Services Administration to determine presence of debarment proceedings against a recipient.
Disclosure:
Voluntary, however, failure to provide the requested information may result in ineligibility
to receive Department of Energy (DOE) surplus personal property. 10 CFR 1008, DOE
Privacy Act Rules apply.
OMB Burden Disclosure Statement
Public recording burden for this collection of information is estimated to average 20 minutes per response, including 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, including suggestions for reducing this burden, to Office of Records and
Business Management (IM-11), Paperwork Reduction Project (1910-5121), U.S. Department of Energy, 1000
Independence Avenue, S.W., Washington, DC 20585, and to the Office of Management and Budget (OMB), Paperwork
Reduction Project (1910-5121), Washington, DC 20503.
RETURN COMPLETED FORM TO THE OFFICE STATED ON THE INVITATION FOR BID (IFB), SOLICITATION,
PROPOSAL, OR OTHER DOCUMENT FOR NON-FEDERAL TRANSFER OF TITLE OR POSSESSION.
INSTRUCTIONS. The purpose of this form is to clear you and/or your business to acquire High-Risk (HR) property being
released from DOE control. This form must be fully completed by all applicants for HR property prior to acceptance by the U.S.
Government and constitutes an integral part of this bid or transfer.
The following applies to all high-risk property subject to sale or non-federal transfer using this form: the use, disposition, export
or re-export of this property is subject to the publications, penalties, or other provisions of the economic programs administered by
the Office of Foreign Assets Control, U.S. Treasury Department, 31 CFR, Chapter V.
Please read the instructions associated with this form. It is your responsibility to fully complete and submit this form. The
information given must be true and correct and will become a part of this contract. Each block MUST have an applicable entry.
If you have already provided the requested information in a previous block, you may enter “SAME AS BLOCK X,” citing the
original block number. If the requested information does not apply to you, insert “NONE” or “NOT APPLICABLE” (do not use
“N/A”). FAILURE TO COMPLETE OR PROVIDE REQUIRED INFORMATION COULD SIGNIFICANTLY DELAY OR
DENY ANY SUBSEQUENT ACTIONS. If you need additional space, you may use separate sheets. The continuation sheet must
include your name and block number relating to that specific block of information. For an applicant who is acting solely as an
Agent, the Principal must sign this form. Return the form to the DOE office address shown in Block 38 of this form.

1

DOE F 580.1
(Rev Date 05/03)

OMB Control Number 1910-5121

The term Approving Official is used to indicate the person authorized to act for the U.S. Government (Organizational Property Management Officer
(OPMO) or Personal Property Official designated by OPMO). For all sales or non-federal transfers of property determined to be items on the Nuclear
Suppliers Group (NSG) Trigger/Dual Use List or the U.S. Munitions List, the Approving Official will forward this form to the Administrator for
National Nuclear Security Administration, (NA-l), through the Office of Export Control Policy and Cooperation (NA-242), for approval before
release of the property. For all sales or non-federal transfers of High-Risk Information Technology, the Approving Official will forward an
information copy of this form to the Property Executive, ME-632.
SECTION I. RECIPIENT INFORMATION
1. Full Name (Last, First, Middle (include Aliases))
5. Social Security Number (SSN)
2. Place of Birth (City or County, State, Country)

6. Alien Registration Card Number or Country Id. Number

4. Telephone Number (Include Area Code)

3. Date of Birth (MM/DD/YYYY)
7. Mailing Address

8. Physical Address

SECTION II. BUSINESS
INFORMATION
kdkdkkdkdkkdkd
Applicability: This statement applies to the property for which we have submitted our bid/offer pursuant to the above identified invitation.
Business/Corporation Headquarters

Branch Office(s) Information

9. Name (Include Acronyms)

10. Name (Include Acronyms)

11. Address (Physical Location) and Telephone Number

12. Address (Physical Location) and Telephone Number

13. Type of Firm:

Sole Proprietorship

14. Nature of End User’s Business

Partnership
Wasi

Corporation

15. Nature of Principal’s Business

Other

16. FIRM’S Identification/Fed. Tax Number

17. All Corporate Officers, Directors, Partners or Agents are to provide, on a separate sheet of paper, their names, addresses,
SSNs, dates and places of birth. Failure to provide this information could significantly delay or deny the award.
SECTION III. DESCRIPTION OF PROPERTY TO BE ACQUIRED BY RECIPIENT
18.

19.
Line Item

Quantity

20.

21.
ECCN
on CCL

Description

22. Section of
NSG
Trigger List

23. Category
on U.S.
Munitions List

SECTION IV. END USE/USER INFORMATION
If this is a negotiated exchange, identify the property being exchanged:
PURPOSE: THE PROPERTY REFERRED TO IN ABOVE SALE/ TRANSFER NUMBER WILL BE UTILIZED FOR THE FOLLOWING:
(Enter an “X” in the appropriate item(s) below. In case of resale, Items 29 or 30 MUST be marked.)
[ ] 24. Retention for the following specific use (See note):

[ ] 25. Resold in the form received for the following use
(See note):

[ ] 26. The property will not be sold or otherwise disposed of for
use outside of the United or to non-U.S. Citizens/Nationals
in the United States.

[ ] 27. The property may be re-exported in the form received
to the following country/countries:

2

DOE F 580.1
(Rev Date 05/03)

OMB Control Number 1910-5121

[ ] 28. Resale after following alteration (description of
final production):

[ ] 29. If sold, name, address, and telephone number of
sub-purchaser(s):

in (Country/Countries):
and distribution in (Country/Countries):

[ ] 30. 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 the contract.
31. 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 FOR SPECIFIC USES: AIRCRAFT - The bidder/recipient certifies that the aircraft will be used: as a flyable
aircraft; as a non-flyable aircraft to be used only for parts, display, or ground instruction, etc.; for resale as a flyable aircraft.
SECTION V. UNDERSTANDING AND NOTIFICATIONS
1. The use, disposition, export and re-export of property is subject to all applicable U.S. Laws and Regulations,including the Arms
Export Control Act (22 USC 2751 et. seq.); Export Administration Act of 1979 (50 USC App. 2401 et seq.) 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 the use or disposition, export or reexport of the property; and
B. Any use, disposition, export or re-export of the property which is not authorized by applicable statute and regulation.
2. The submission of false or misleading information and/or concealment of any material facts regarding the use, disposition or
export of property may constitute a violation of provisions of 18 USC 793/1001, 22 USC 277812779, 50 USC App. 2410, and 50
USC App. l-44. Sanctions for violations will be in conformity with U.S. laws and regulations (including Federal Acquisition
Regulations) and may include the denial of U.S. export privileges and of any participation in future U.S. Government contracts.
3. The Sale/Transfer Document Number must be referenced when submitting an application for an export license for High-Risk
property to the Department of State or Department of Commerce, as appropriate. It is the responsibility of the purchaser/bidder to
determine what the applicable requirements may be and to obtain all necessary authorizations and approvals.
4. Any export of High-Risk property identified on the NSG Trigger/Dual Use List or U.S. Munitions List, must be done in full
compliance with United States export control laws and regulations. This understanding must be conveyed if such items are
transferred to any recipient. Subsequent recipients of DOE High-Risk property identified on the NSG Trigger/Dual Use List or U.S.
Munitions List are subject to all export laws and regulations, and need to understand that this requirement shall be passed along to
subsequent recipients.
5. Each time High-Risk property is transferred, the information regarding the above laws and regulations must always be passed to
all subsequent purchasers/receivers, regardless whether a U.S. or foreign person. If subsequent purchaser/receiver is not a U.S.
citizen/national or permanent resident of the United States of America, seller/transferor must obtain a validated export license or
other authorization, prior to transfer. Records of resale must remain available for DOE review.
6. The Purchaser/Recipient agrees to cooperate with and to permit all authorized Government representatives to inspect and verify
the existence and condition of export-controlled High-Risk property.
SECTION VI. CERTIFICATION STATEMENT TO BE SIGNED BY RECIPIENT
1. I do certify that all information given in this statement is true and correct to the best of my knowledge and belief and I 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/transfer 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 stated 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.

3

DOE F 580.1
(Rev Date 05/03)

OMB Control Number 1910-5121

2. I acknowledge having been advised that the export of High-Risk property may be subject to the U.S. Government export control
laws and regulations, and may not be exported and, its export may require a valid State/Commerce Department export license, or
other authorization. This understanding must be conveyed if such items are transferred to any recipient. Subsequent recipients of
DOE High-Risk property identified on the NSG Trigger/Dual Use List or U.S. Munitions List are subject to all export laws and
regulations, and need to understand that this requirement shall be passed along to subsequent recipients.
A. Should I transfer property to another U.S. citizen/national or permanent resident, I will obtain their signature as having read and
understood this restriction and their certification that they will place the same restriction on any subsequent transfer and obtain
signature thereto and will provide a copy to the Approving Official.
B. Should I transfer property to a non-U.S. citizen/national or non-permanent resident, I will do so in full compliance with United
States export control and regulations and if necessary, obtain a validated State/Commerce Department export license or other
authorization.
3. Neither the applicant, corporate officers, directors nor partners are:
A. The subject of an indictment for or has been convicted of violating any of the U.S. Criminal statutes enumerated in 22 CFR
120.27 since the effective date of the Arms Export Control Act, Public Law 94-329, 90 Statute 729 (June 30, 1976); or
B. 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 DOE Form 580.1 is
[ ] a Citizen of the United States of America, or
[ ] lawfully admitted to the United States Permanent Residency and maintains such residence under the Immigration and
Nationality Act, as amended (8 USC 1101 (a), 20, 60 Statute 163), or
[ ] a Citizen of

, and/or

[ ] is an official of a foreign government entity in the United States.
32. Name (Type or Print)

33. Signature

34. Date Signed
(MM/DD/YYYY)

SECTION VII. U.S. DEPARTMENT OF ENERGY APPROVING OFFICIAL
35. Name (Type or Print)

36. Title

37. Telephone Number

38. Address

39. Approving Official requires
notification of resale/transfer
of this property (see Section VI,
2.A&B)

40. Signature

E-Mail:

[ ] YES

[ ] NO

SECTION VIII. CERTIFICATION STATEMENT TO BE SIGNED BY ANY U.S. CITIZEN/NATIONAL/PERMANENT
RESIDENT HOLDER TO WHOM MATERIAL IS SOLD
I
, acknowledge having been advised that the High-Risk property I have purchased/
received from Mr./Ms./Mrs./Miss
on (date)
, is controlled by the U.S.
Government and cannot be transferred (exported, sold, given) to a non-U.S. citizen/National or non-Permanent Resident without a
validated State/Commerce Department export license.
Should I transfer this property to another U.S. Citizen/National or U.S. Permanent Resident, I will obtain their signature (1) as having
read and understood this restriction, and (2) as their certification that they will place the same restriction on any subsequent transfer
and obtain a signature to retain in their files. Upon request, a copy of the signed certification will be provided to the Department of
Energy Approving Official.
Should I transfer this property to a non-U.S. Citizen/National or non-Permanent Resident, I will obtain a validated State/Commerce
Department export license before I transfer the High-Risk property to that person. I will not transfer this property to countries,
regimes and nationals targeted under the sanctions programs administered by the U.S. Treasury Departments Office of Foreign
Assets Control.
47. Name (Type or Print)

48. Signature

49. Date Signed

4

DOE F 580.1
(Rev Date 05/03)

OMB Control Number 1910-5121

U.S. DEPARTMENT OF ENERGY
HIGH-RISK PROPERTY
END-USE CERTIFICATE INSTRUCTIONS
12/09/2002
End-Use Certificate (EUC), Department of Energy (DOE) Form 580.1, is required by all DOE offices and contractors when possession
of High-Risk Property Items is being transferred as the result of sale or transfer (i.e., exchange, transfer, donation, grant).
INSTRUCTIONS FOR COMPLETING DOE FORM
All individuals wanting to acquire DOE property, identified as High-Risk property, are required to fullycomplete this EUC, DOE Form
580.1. It is your responsibility to fully complete the DOE Form 580.1. The use of “homemade” EUCs is discouraged because they are
not covered under the Paperwork Reduction Act. Due to the critical nature of this document, failure to comply with these instructions or
use of a “Home made” EUC will cause your transaction to be placed on hold to undergo additional review. This could significantly
delay or preclude the award/offer.
Type or print all entries clearly. When providing the required information and additional space is needed, you may use a separate sheet of
paper citing the appropriate block number and/or letter. Every block must have an entry. When the information being requested does not
apply to you, the only entries which will be acceptable are:“NONE”, “DOES NOT APPLY”, OR “NOT APPLICABLE” (do not use N/A
or N/R). If you have previously entered similar information in another block, you should cite that block number and/or letter; i.e.,
“SAME AS BLOCK X”. Return to the Approving Official (Organizational Property Management Officer, or their designated Personal
Property Official) for review to ensure the EUC is complete (see block 38 for return address).

AT TOP OF FORM
SALE/TRANSFER DOCUMENT CONTROL NUMBER:
Enter the number of the Invitation for Bid (IFB), contract offer, proposal number, or order number which is used to identify
the sale or non-Federal transfer (if it has not been pre-printed).
BE SURE TO READ ALL INSTRUCTIONS BEFORE COMPLETING THE EUC.

SECTION I - RECIPIENT INFORMATION
BLOCK 1. FULL NAME (LAST, FIRST, MIDDLE (INCLUDE ALIASES)):
Please print/type your complete name so it is legible. This should be the name of the individual who is signing this form.
The name you place here must be the same as the name placed on the bid document/exchange proposal. Do not use initials in
place of first and middle name; full name must be provided. If you do not have a middle name, use NMN (No Middle Name).
Include any other names ever used (i.e., maiden name, nick- names, acronyms, aliases, doing business as (dba) and/or “also
known as (aka)”name(s)). Failure to provide your complete name could result in delays or denial in obtaining approval for
release of the property. If the bid is for a business, the individual authorized to sign this EUC must provide his/her name in
this blank.
BLOCK 2. PLACE OF BIRTH (CITY OR COUNTY, STATE, COUNTRY):
City/County name must be spelled out. Only the two-letter or standard abbreviation for the State or Country is acceptable.
If the bid is for an individual, that individual’s Place of Birth must be provided in this block.
If the bid is for a business, the individual signing this EUC must provide their Place of Birth in this Block.
BLOCK 3. DATE OF BIRTH (DoB): Enter DoB as Month/Day/Year (MM/DD/YYYY).
If the bid is for an individual, that individual’s Date of Birth must be provided in this block.
If the bid is for a business, the individual signing this EUC must provide their Date of Birth in this block.
BLOCK 4. TELEPHONE NUMBER (INCLUDE AREA CODE):
If the bid is for an individual, that individual’s telephone number (including area code) must be provided in this block.
If the bid is for a business, the individual signing this EUC must provide their telephone number (including area code) in
this block.
BLOCK 5. SOCIAL SECURITY NUMBER (SSN) OR COUNTRY ID NUMBER:
If the bid is for an individual, that individual’s SSN must be provided in this block.
If that bid is for a business, the individual signing this EUC must provide there SSN in this block.

1

DOE F 580.1
(Rev Date 05/03)

OMB Control Number 1910-5121

BLOCK 6. ALIEN REGISTRATION CARD NUMBER OR COUNTRY IDENTIFICATION NUMBER:
If the bid is in the name of a Permanent Resident, enter your Alien Identification Number.
If the bid is in the name of a Non-U.S. Citizen/National, non-Permanent Resident acting for a foreign government, enter your
Country Identification Number.
BLOCK 7. MAILING ADDRESS:
Enter complete mailing address. Street and City names must be spelled out; abbreviations are unacceptable. Post Office Box
is acceptable. The two-letter or standard abbreviation for the State or Country is acceptable.
If the bid is for an individual, that individual’s mailing address must be provided in this block.
If the bid is for a business, the business’s mailing address must be provided in this block.
BLOCK 8. PHYSICAL ADDRESS:
Enter complete physical address. Street and City names must be spelled out; abbreviations are unacceptable. Post Office Box
is not acceptable. The two-letter or standard abbreviation for the State or Country is acceptable.
If the bid is for an individual, that individual’s physical address (Street, City, State, Zip) must be provided in this block. If the
physical address is the same as the mailing address (not a Post Office Box), enter “Same as MAILING ADDRESS.”
If the bid is for a business, that business’s physical address (Street, City, State, Zip) must be provided in this block. If the
physical address is the same as the mailing address (not a Post Office Box), enter “Same as MAILING ADDRESS.”

SECTION II - BUSINESS INFORMATION
BLOCK 9. NAME OF FIRM’S BUSINESS/CORPORATION HEADQUARTERS (INCLUDE
ACRONYMS):
If the bid is in the name of an individual, enter “Not Applicable.”
If the bid is in a company’s name, the individual signing this EUC must provide the official company headquarters name in
this block (include aliases/acronyms/trade styles.)
BLOCK 10. NAME OF FIRM’S BRANCH OFFICE INFORMATION (INCLUDE ACRONYMS):
If the bid is in the name of an individual, enter “Not Applicable.”
If the bid is in a company’s name, the individual signing this EUC must provide all official company branch name(s) in the
block (include aliases/acronyms/trade styles).
If the official company branch and headquarters’ names are the same, enter “Same as Block 9.”
If the bid is in a company’s name and there is no branch office for this company, enter “Not Applicable.”
BLOCK 11. ADDRESS (PHYSICAL LOCATION ) & TELEPHONE NUMBER FOR BUSINESS/CORPORATION
HEADQUARTERS:
Give full physical address. Street and City names must be spelled out; abbreviations are unacceptable. Only two-letter (or
standard) abbreviation for State or Country is acceptable.
If the bid is in the name of an individual, enter “Not Applicable.”
If the bid is in a company’s name, the individual signing this EUC must provide the complete physical address of company
headquarters. (Post Office Box is unacceptable.)
BLOCK 12. ADDRESS (PHYSICAL LOCATION ) & TELEPHONE NUMBER FOR BRANCH OFFICE(S) INFORMATION:
Give full physical address. Street and City names must be spelled out; abbreviations are unacceptable. Only two-letter (or
standard) abbreviation for State or Country is acceptable.
If the bid is in the name of an individual, and there are no branch offices, enter “Not Applicable.”
If the bid is in a company’s name, the individual signing this EUC must provide the complete physical address (Street, City,
State, Zip) of all company branch office(s). (Post Office Box is Unacceptable.)
If company’s branch and headquarters offices use the same address, enter same as Block 12.
If there are no branch offices, enter “Not Applicable.”
BLOCK 13. TYPE OF FIRM:
If the bid is for an individual, enter “Not Applicable.”
If the bid is for a business, check the box that most closely describes the organization”
“Sole Proprietorship” = solitary owner/independent control;
“Partnership”
= two or more persons contractually associated as joint principals in a business with joints rights
and responsibilities;

2

DOE F 580.1
(Rev Date 05/03)

OMB Control Number 1910-5121

“Corporation”
“Other”

= an association or group of individuals united in trade or similar interests that has filed Articles of
Incorporation;
= (The signer of this EUC must check “Other” and specify affiliation with official bidder.)
= Principal (Person having controlling authority).
= Agent (Person acting for or in place of another by authority from him.)

BLOCK 14. NATURE OF END-USER’S BUSINESS:
This should best describe the type business/interest of the ultimate end-user.
BLOCK 15. NATURE OF PRINCIPAL’S BUSINESS:
This should best describe the type business/interest of the official bidder.
BLOCK 16. FIRM’S IDENTIFICATION/FEDERAL TAX NUMBER:
If the bid is in the name of an individual, enter “Not Applicable.”
If the bid is in a company’s name and that company does not have a Federal Tax Number but is using some other form of tax
identifying number (i.e., a personal SSN) list that number and specify (i.e., SSN registered to (provide name)).
BLOCK 17. ALL CORPORATE OFFICERS, DIRECTORS, PARTNERS OR AGENTS ARE TO PROVIDE THEIR NAMES,
ADDRESSES, SSNs, DATES & PLACES OF BIRTH...:
Failure to comply will cause your transaction to be placed on hold or not considered.
If the bid is in the name of an individual, enter “Not Applicable.”
If the bid is for a company, the required information for each of the officers, directors, and Partner is to be on separate sheets
of paper.

SECTION III - DESCRIPTION OF PROPERTY OBTAINED BY RECIPIENT
COLUMN 18. LINE ITEM:
Enter Line Item Number from sale/transfer document of commodity being obtained.
COLUMN 19. QUANTITY:
Enter Number of Items being obtained for each line item.
COLUMN 20. DESCRIPTION:
Enter Full Description as noted on sale/transfer document for commodity being obtained.
COLUMN 21. ECCN ON CCL:
The Export Control Classification Number (ECCN) on the Department of Commerce Control List (CCL). Reference Part 774
on website http://w3.access.gpo.gov/bis/ear/ear_data.html.
COLUMN 22. SECTION OF NSG TRIGGER LIST:
Reference the section of the Nuclear Suppliers Group (NSG) export Trigger List that controls the equipment being
transferred. Reference Annex A on website http://www.iaea.org/wordatom/documents/infcircs/others/infcirc254.shtml.
COLUMN 23. CATEGORY ON U.S. MUNITIONS LIST:
Reference the category on the U.S. Munitions List that controls the equipment being transferred.
Reference http://www.ciponline.org/facts/munilist.htm

SECTION IV. - END-USE/USER INFORMATION
If this is a negotiated exchange, identify the item(s) you will be providing the Government in this exchange:
(Complete this information)
.
PURPOSE. THE PROPERTY REFERRED TO IN ABOVE SALE/TRANSFER NUMBER WILL BE UTILIZED FOR THE
FOLLOWING: Enter an “X” in the appropriate item(s) below. In the case of resale, item 29 or 30 must be marked in addition to any
other item.
BLOCK 24. Retention for the following specific use (see Note at bottom of Section IV.):
If property is being retained for official bidder’s own use, explain intended use.
If statement in Block 24 does not apply, enter “Not Applicable” and go to Block 25.

3

DOE F 580.1
(Rev Date 05/03)

OMB Control Number 1910-5121

BLOCK 25. Resold in the form received for the following use (See Note):
If property is being resold, give specific information about resale customer’s intended use.
If statement in Block 25 does not apply, enter “Not Applicable” and go to Block 26.
BLOCK 26. The property will not be sold or otherwise disposed of for use outside of the U.S. or to non-U.S. Citizens/Nationals in
the United States:
Check this box if applicable.
If statement in Block 26 does not apply, enter “Not Applicable” and go to Block 27.
BLOCK 27. The property may be re-exported in the form received to the following country/countries:
Check this box if applicable, and list the country(ies). Attach valid, current Department of State Registration (for export).
If statement in Block 27 does not apply, enter ‘Not Applicable” and go to Block 28
BLOCK 28. Resale after following alteration Description of final production: Describe the altered product;
In Country/Countries: List all countries where this product will be sold. (If necessary, use a separate sheet to list countries.
Identify this as BLOCK 28 on the sheet of paper);
And distribution in Country/Countries: List all countries where this product will be distributed (If necessary, use a separate
sheet to list countries. Identify this as BLOCK 28 on the sheet of paper);
If statement in Block 28 does not apply, enter “Not Applicable” and go to Block 29.
BLOCK 29. If sold, name address, and telephone number of sub-purchaser(s):
Provide the full name, physical address and telephone number of the individual/company that purchased the item(s).
If statement in Block 29 does not apply, enter ‘Not Applicable.”
BLOCK 30. 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.
If this block does not apply to you, enter “Not Applicable.”
BLOCK 31. Additional Information:
State any other material facts relating to end user and use of property that may be of value in considering the proposal.
If this block does not apply to you, enter ‘Not Applicable.”

SECTION V. - UNDERSTANDING AND NOTIFICATIONS
Please read carefully. This section cites the various laws and regulations you must adhere to which govern the use, disposition and
export of property.

SECTION VI. - CERTIFICATION STATEMENT TO BE SIGNED BY RECIPIENT
This section is selfexplanatory. By signing and dating this form, you are certifying that all the information you are providing
is true and correct and you understand and agree to all the provisions in this end use certificate. This form will become part of
the contract.
ITEMS 1, 2, & 3:
Please read carefully.
ITEM 4. The person signing this DOE Form 580.1 is:
Check the block that applies to you and fill out any applicable portion.
BLOCK 32. NAME:
This section is self-explanatory. Type or Print your complete first, middle and last name. If you do not have a middle name,
use NMN.
BLOCKS 33 & 34.
By signing and dating this form, you are certifying that all the information you are providing is true and correct and you
understand and agree to all the provisions in this end-use certificate. This form will become part of the contract.

4

DOE F 580.1
(Rev Date 05/03)

OMB Control Number 1910-5121

SECTION VII. - DEPARTMENT OF ENERGY APPROVING OFFICIAL
BLOCKS 35,36,37,38,39.
These blocks will be completed by the DOE Approving Official before providing the form to the recipient. RETURN THIS
COMPLETED FORM TO THE ADDRESS LOCATED IN BLOCK 38 OF THIS SECTION for review and signature.
BLOCK 40. Signature of DOE Approving Official
DOE Approving Official will review the EUC for completeness, sign, and will forward to NA-1, through NA-242, as
appropriate.

SECTION VIII. - CERTIFICATION STATEMENT TO BE SIGNED BY ANY U.S.
CITIZEN NATIONAL/PERMANENT RESIDENT HOLDER TO WHOM
EQUIPMENT IS SOLD
This section is not for the original purchaser to complete. It is intended for completion by the sub-purchaser. This section is
to be completed only when any of the property identified in Blocks 18 through 23, of the End-Use Certificate, is being
transferred (sold, donated, or given) by the party identified in Block 1. When the sub-purchaser signs and dates this section, it
is acknowledged that the seller has advised that sub-purchaser of the export requirements stated in Section V. of this form and
that the sub-purchaser agrees to be bound by the U.S. laws cited. The sub-purchaser also agrees to inform any subsequent
buyers of the conditions stated in this End-Use Certificate when transferring (selling, donating, or giving) the
property. The certificate must be completed in all subsequent transfers of the equipment.
> The PRINTED COMPLETE NAME of the acquiring individual is placed in the first blank of the certificate.
> The PRINTED COMPLETE NAME of the individual currently holding title to the equipment is placed in the second
blank of the certificate.
> The DATE (written legibly) OF THE TRANSFER is placed in the third blank of the certificate.
BLOCK 47. NAME:
This section is to be completed by the individual acquiring the equipment. Type or Print your complete first, middle and last
name. If you do not have a middle name, use NMN (No Middle Name).
BLOCKS 48 & 49.
By signing and dating this form, you are certifying that all the information you are providing is true and correct and you
understand and agree to all the provisions in this end-use certificate. This form will become part of the contract.

5