Draft Form

WORKING DRAFT

DS-XXXX

PART A

Broker Name_____Broker Registration Code_____Reporting Period

Certification: The applicant or the chief executive officer, president vice-presidents, other senior officers or officials (e.g. comptroller, treasurer, general counsel) or any member of the board of directors in the subject of an indictment for or has been convicted of violating any foreign criminal statutes dealing with the subject mater of those U.S. criminal statues enumerated in 120.27 of this subchapter, or are ineligible to contract with, or to receive a license or other approval to import defense articles or defense services from, or to receive an export license or other approval, or to receive a license or other approval to engage in the business of brokering from any agency of a foreign government. A person subject to any such status under foreign law shall be deemed generally ineligible.

Signature: ______________

PART B. Prior Written Approval

DDTC No. Additional Info SME Consideration Consideration Activity

Received Payor/source

______ _____ _____ _____ _____ _____

text box text box Y/N text box text box Y/N

PART C. Exemption

Exemption Prior Written Other Written Describe Role of Nationality Consideration Consideration Territory USML

Citation Approval Approval Activity Persons of Persons Received Payor/source Cat/sub

_____ _____ _____ _____ _____ _____ _____ _____ _____ _____

Text box text box test box text box text box text box text box text box drop dwn drop dwn

Continued

SME Military Designation/ Source Quantity Value Security End Use End User Third Party DCS or FMS

Model Number Classification Transfer

_____ _____ _____ _____ _____ _____ _____ _____ _____ _____

Y/N Text box text box text box text box text box text box text box text box text box

Rev 3/27/08

U.S. Department of State

Instructions for Reporting Brokering Activities

In accordance with 22 CFR 129.9

PART A

Broker Name The name as it appears in Block 1 of the DS-2032 registration form (129.9(a))

Broker Reg Code The registration code issued by DDTC to the applicant filing this report. (129.3, 129.9(a)). Registration required if

exemption used.

Reporting Period Due by January 31 of each year reporting prior calendar year activities. (129.9(a)). Report must be filed even if no

Activity occurred (129.9(a)(3)

Signature Senior officer as described in 126.13(e) and 129.4(a) and includes certification statement (129.4(e)

PART B

DDTC No The DDTC issued authorization describing all aspects of the brokering activities. (129.9(b) and 129.8).

Additional Info Provide information required by 129.8(b) that was not available at the time of the request for prior approval was

submitted and approved. Identify specifically by ITAR entry, e.g. 129.8(b)(iii).

SME Yes/No response (120.7. And what about the 129.7(c)(3)?)

Consideration Rec The money or other benefits received for either a successful transaction or benefits received during the year to facilitate

activities that may not have resulted in concluding a brokering transaction, e.g., retainers, fees or other benefits.

Consideration Payor/ The payor or source of the benefits.

Source

Activity Yes or No answer for each entry. If no activity undertaken during the year under a prior written approval, complete the

information in Part and mark “NO”. A report must be filed each year regardless of whether or not activity occurred.

(129.9(a)(3)

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PART C

Exemption Citation Enter the exemption used, e.g. 129.7(c), 129.7(d) or 129.8(b).

Prior Written Approval If using 129.8(b), the broker should enter the prior written approval authorizing received by the Part 122

manufacturer/exporter under which the broker was listed as a party to the transaction.

Other Written Approval If using 129.8(b), the broker should enter the license or other written authorizations received by the Part 122 manufacture/exporter under which the broker was listed as a party to the transition.

Describe Activity

Role of Persons

Nationality of Persons

Consideration Rec

Consideration Payor/

Source

Territory

USML Cat/sub cat

SME

Military Designation/

Model Number

Source

Quantity

Value

Security Classification

End Use

End User

Third Party

DCS or FMS

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