Form DS4142 DS-4142 Annual Brokering Report (22 CFR 129)

Reporting on Brokering Activities

BrRep, Draft Form

Reporting on Brokering Activities

OMB: 1405-0141

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U.S. Department of State

Instructions for Annual Brokering Report (22 CFR 129)


PART A


  • Broker Name - The name of the registrant as it appears in the DS-2032 registration form.

  • Broker Reg Code - The registration code issued by DDTC to registrant filing the report. Registration required if exemption used.

  • Reporting Period - Twelve month period identified in the DDTC renewal letter. Report must be filed even if no activity occurred.

  • Signature - Senior officer as described in 126.13(e) and 129.4(a).

PART B


  • Prior Approval No. - The DDTC issued authorization describing all aspects of the brokering activities.

  • Prior Notification No. - The DDTC issued prior notification.

  • Consideration Received/ Date - The money or other benefits received for either a successful transaction or benefits received during the year to facilitate activities that may or may not have resulted in concluding a brokering transaction, e.g., retainer, fees, commissions, or other benefits.

  • Consideration Source - List the payer/s or source of the benefits, name, address and country.

  • Additional Info - Provide ancillary information as may be useful or required.


PART C


  • Exemption Citation - Select the exemption used.

  • Describes Activity - Briefly describe the brokering activity, the persons involved and their role.

  • Nationality of Person/s - State nationality of all persons by clicking nationality.

  • Consideration Received/ Date - The money or other benefits received for either a successful transaction or benefits received during the year to facilitate activities that may or may not have resulted in concluding a brokering transaction, e.g., retainer, fees, commissions, or other benefits.

  • Consideration Source - List the payer/s or source of the benefits, name, address and country.

  • Country/s - Identify the country/s in which the brokering activity takes place.

  • USML Cat/Sub Cat - Both the category and sub category must be identified.

  • Security Classification - US Confidential, US Secret, Foreign classified [I included because in the 129.7 (d)]

  • Military Designation/Model No. - Briefly describe the item, e.g., of ammunition provide caliber, if aircraft provide nomenclature version.

  • Source - Name, address and country where the items located.

  • Quantity - Identify in units best suited for the defense articles or defense services.

  • Value - In US dollars.

  • End Use - Describe end use.

  • End User - State end user.

  • DCS or FMS - Select one, or both, as applicable.


*Public reporting burden for this collection is estimated to average 2 hours per response, including time required for searching existing data sources, gathering the necessary data, providing the information required, and reviewing the final collection. Send comments on the accuracy of this estimate of the burden and recommendations for reducing it to: Department of State (A/RPS/DIR) Washington, D.C. 20520




U.S. Department of State

DS-4142 Annual Brokering Report (22 CFR 129)

(SEE INSTRUCTIONS PAGE)

(Attach additional sheets if necessary)

OMB No. 1405-0141

EXPIRATION DATE: 02-28-10

*ESTIMATED BURDEN: 2Hours

(Instruction Page)


Part A. Certification


Broker Name


Broker Registration Code


Reporting Period


Is the 12 month period identified in the Renewal Letter


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 is not the subject of an indictment for, or has been convicted of, violating the US criminal statutes enumerated in Part 120.27 or any foreign criminal statutes dealing with the subject matter in Part 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 the US Government or any agency of a foreign government. A person subject to any such status under foreign law shall be deemed generally ineligible.


Signature


Date (MM/DD/YYYY)


Part B1. Prior Written Approval


#

Prior Approval No.

SME

Consideration Received/Date

Consideration Source

Additional Information



















Part B2. Prior Notification


#

Prior Notification No.

SME

Consideration Received/Date

Consideration Source

Additional Information




















Additional Pages Attached

Part C. Exemption (129.6)


#

Exemption Citation

Describe Activity











#

Nationality of Persons

Consideration Received/Date

Consideration Source

Country/s

USML Cat

Sub Cat

Security Classification


























#

Military Designation/ Model No.

Source

Qty

Value

















#

End Use

End User

DCS or FMS














Additional Pages Attached



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AuthorMeredith J Carlton
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