Form DHS FORM 10044 DHS FORM 10044 Supplier's Declaration of Compliance

Project 25 Compliance Assessment Program
Supplier’s Declaration of Compliance Form
Cover Sheet
1. Department Name: Department of Homeland Security
2. Component/Agency Name: Science and Technology Directorate
3. OMB Control Number: 1640-New
4. Expiration Date: TBD (Three years from approval date)
5. Agency Form Number: DHS 10044
6. Name of Form: Supplier’s Declaration of Compliance Form
7. Purpose of Form: Allows Equipment Suppliers to declare compliance with Project 25
compliance standards.
8. How to submit: The completed form may be submitted via facsimile, email, or mail to the OIC
P25 CAP Program Manager.

Project 25 Compliance Assessment Program

OMB FORM #1040-XXX
Expires: xx/xx/xxxx

Department of Homeland Security, Science & Technology Directorate

SUPPLIER’S DECLARATION OF COMPLIANCE (SDoC)
{Company Name}
{Company Department}
{Street Address}, {City}, {State} {Zip}
Customer Contact: {name}
Phone: xxx-xxx-xxxx Fax: xxx-xxx-xxxx
E-mail: {e-mail address}
URL: http://www.companyname.com
Product Name: {Name of product}
Installed options: {List of options}
Other Devices Tested:
{Manufacturer}

{Product Name, Definition,
and Unique ID}

{Installed Options}

{Company Name} hereby declares that the above referenced product(s) pass the
test cases listed in the following Project 25 Telecommunications Systems Bulletins
in their entirety without exclusions:
TSB-102.YYYY, Project 25 Compliance Assessment Program Definition of
Compliance Assessment – Transceiver Performance; Conventional Mode
Subscriber
TSB-102.XXXX, Project 25 Compliance Assessment Program Definition of
Compliance Assessment – Transceiver Performance; Trunking Mode Subscriber
The Summary Test Reports performed at P25 CAP Recognized Laboratory Code:
XXX are identified as follows:

An agency may not conduct or sponsor an information collection and a person is not required to respond to this
information collection unless it displays a current valid OMB control number and an expiration date. The control
number for this collection is 1640-XXXX and this form will expire on XX/XX/XXXX. The estimated average time to
complete this form is 60 minutes per respondent. If you have any comments regarding the burden estimate you can
write to Department of Homeland Security, Science and Technology Directorate, Washington, DC 20528.

DHS FORM 10044 - June 2008

Test Report Identification: 123456 issued on MMM DD, YYYY
Test Report Identification: 789101 issued on MMM DD, YYYY
______________________________
Issue date

__________________________________________________
Supplier’s Authorized Representative Signature

________________________________________________________
Supplier’s Authorized Representative Printed Name