Form DS-4184 Risk Analysis Information

OMB APPROVAL NO.
EXPIRES:
ESTIMATED BURDEN: 75 Minutes*

U.S. Department of State

RISK ANALYSIS INFORMATION

PART 1: INFORMATION ABOUT CONTRACT/GRANT/COOPERATIVE AGREEMENT
Name of Prospective Contractor/Grantee

Type (Contract, Grant, Other):
Contract

US Dollar Value of Contract/Grant (All Years) Contract/Grant Start Date (mm-dd-yyyy)

Grant

Other

Contract/Grant End Date (mm-dd-yyyy) Solicitation Number

Purpose of Contract/Grant

Address of Prospective Contractor/Grantee

Phone Number

Cellphone Number

Fax Number

E-mail

PART 2: AFGHANISTAN
Please provide the following information if proposed contract or grant work will be in Afghanistan.
Afghanistan Business License Number

Joint Contingency Contraction System (JCCS) Number

PART 3: CERTIFICATION
I certify that I have taken reasonable steps (in accordance with sound business practices) to verify the information contained in this form. I understand
that the U.S. Government may rely on the accuracy of such information in processing this request.
Authorizing Official's Name (Last, First, MI)

Title/Organization

Signature

Date (mm-dd-yyyy)

PART 4: SUBMISSION DETAILS (GOVERNMENT USE ONLY)
Request Number

Request Initiator

Project Name

Date Received (mm-dd-yyyy)

DS-4184
XX-XXXX

Page 1 of 5

PAPERWORK REDUCTION ACT STATEMENT
*Public reporting burden for this collection of information is estimated to average 75 minutes 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 currently 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: A/GIS/DIR, Room 2400 SA-22, U.S. Department of
State, Washington, DC 20522-2202.

PRIVACY ACT STATEMENT
Authority: 18 U.S.C. 2339A, 2339B, 2339C, 22 U.S.C. 2151 et seq., Section 559 of the Appropriations Act, Executive Orders 13224, 13099, and
12947, and Homeland Security Presidential Directive 6.
Purpose: The information in the system supports the vetting of directors, officers, or other employees of organizations who apply for Department of
State contracts, grants, or other funding. The information collected from the organizations and individuals is specifically used to conduct screening to
ensure that Department funds are not used to provide support to entities or individuals deemed to be a risk to US national security interests.
Routine Uses: The information is used to make determinations on applications for contracts, grants, or other funding and may be disclosed to the
United States Agency for International Development (USAID) for collaborative and vetting programs.
Disclosure: Disclosure of the information provided on this form will be done in accordance with the Department of State's System of Records Notice
concerning the Risk Analysis and Management System (RAM) (enter SORN #) which establishes the routine uses and Privacy Act exceptions which
apply to this system.

INSTRUCTIONS
Appendix Key Personnel (Use continuation sheets, as necessary)
Key personnel may include but is not limited to:
The organization/company's President, Vice President, Executive Director, Deputy Executive Director, Chief Executive Officer, Chief Operating
Officer, Treasurer, Secretary, and the Board of Directors.
It may also include Program Managers or Project Managers.
Proposed Subcontractors or Sub-grantees must also complete a separate Information Form listing their key personnel.
Indicate "N/A" if a category does not apply. If no organization or company is listed, complete the information on each individual who will receive
cash or in-kind assistance (including technical assistance).

APPENDIX: KEY PERSONNEL INFORMATION
Name (Last, First, MI)

Other Names Used ("also known as", nicknames, alias, different spelling)

Place of Birth

Date of Birth (mm-dd-yyyy)

Gender:
Male

Citizenship(s)

US citizen or Permanent Legal Resident?

Yes

Female

No

If yes, provide your U.S. Passport or Social Security Number
Government Issued Photo ID Type

Government Issued Photo ID Number

Address

Current Employer

Country of Issuance

Phone Number

Cellphone Number

Fax Number

E-mail

Organizational Title

Project Title

Afghan Citizen Use Only (If Section 2 Has Been Completed)
Father's Name

Tazkera Number

DS-4184

Tribe

Passport Number

Country of Issuance

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APPENDIX: KEY PERSONNEL INFORMATION
Name (Last, First, MI)

Other Names Used ("also known as", nicknames, alias, different spelling)

Place of Birth

Date of Birth (mm-dd-yyyy)

Gender:
Male

Citizenship(s)

US citizen or Permanent Legal Resident?

Yes

Female

No

If yes, provide your U.S. Passport or Social Security Number
Government Issued Photo ID Type

Government Issued Photo ID Number

Address

Current Employer

Country of Issuance

Phone Number

Cellphone Number

Fax Number

E-mail

Organizational Title

Project Title

Afghan Citizen Use Only (If Section 2 Has Been Completed)
Father's Name

Tazkera Number

Tribe

Passport Number

Country of Issuance

Name (Last, First, MI)

Other Names Used ("also known as", nicknames, alias, different spelling)

Place of Birth

Date of Birth (mm-dd-yyyy)

Gender:
Male

Citizenship(s)

US citizen or Permanent Legal Resident?

Yes

Female

No

If yes, provide your U.S. Passport or Social Security Number
Government Issued Photo ID Type

Government Issued Photo ID Number

Address

Current Employer

Country of Issuance

Phone Number

Cellphone Number

Fax Number

E-mail

Organizational Title

Project Title

Afghan Citizen Use Only (If Section 2 Has Been Completed)
Father's Name

Tazkera Number

DS-4184

Tribe

Passport Number

Country of Issuance

Page 3 of 5

APPENDIX: KEY PERSONNEL INFORMATION
Name (Last, First, MI)

Other Names Used ("also known as", nicknames, alias, different spelling)

Place of Birth

Date of Birth (mm-dd-yyyy)

Gender:
Male

Citizenship(s)

US citizen or Permanent Legal Resident?

Yes

Female

No

If yes, provide your U.S. Passport or Social Security Number
Government Issued Photo ID Type

Government Issued Photo ID Number

Address

Current Employer

Country of Issuance

Phone Number

Cellphone Number

Fax Number

E-mail

Organizational Title

Project Title

Afghan Citizen Use Only (If Section 2 Has Been Completed)
Father's Name

Tazkera Number

Tribe

Passport Number

Country of Issuance

Name (Last, First, MI)

Other Names Used ("also known as", nicknames, alias, different spelling)

Place of Birth

Date of Birth (mm-dd-yyyy)

Gender:
Male

Citizenship(s)

US citizen or Permanent Legal Resident?

Yes

Female

No

If yes, provide your U.S. Passport or Social Security Number
Government Issued Photo ID Type

Government Issued Photo ID Number

Address

Current Employer

Country of Issuance

Phone Number

Cellphone Number

Fax Number

E-mail

Organizational Title

Project Title

Afghan Citizen Use Only (If Section 2 Has Been Completed)
Father's Name

Tazkera Number

DS-4184

Tribe

Passport Number

Country of Issuance

Page 4 of 5

APPENDIX: KEY PERSONNEL INFORMATION
Name (Last, First, MI)

Other Names Used ("also known as", nicknames, alias, different spelling)

Place of Birth

Date of Birth (mm-dd-yyyy)

Gender:
Male

Citizenship(s)

US citizen or Permanent Legal Resident?

Yes

Female

No

If yes, provide your U.S. Passport or Social Security Number
Government Issued Photo ID Type

Government Issued Photo ID Number

Address

Current Employer

Country of Issuance

Phone Number

Cellphone Number

Fax Number

E-mail

Organizational Title

Project Title

Afghan Citizen Use Only (If Section 2 Has Been Completed)
Father's Name

Tazkera Number

Tribe

Passport Number

Country of Issuance

Name (Last, First, MI)

Other Names Used ("also known as", nicknames, alias, different spelling)

Place of Birth

Date of Birth (mm-dd-yyyy)

Gender:
Male

Citizenship(s)

US citizen or Permanent Legal Resident?

Yes

Female

No

If yes, provide your U.S. Passport or Social Security Number
Government Issued Photo ID Type

Government Issued Photo ID Number

Address

Current Employer

Country of Issuance

Phone Number

Cellphone Number

Fax Number

E-mail

Organizational Title

Project Title

Afghan Citizen Use Only (If Section 2 Has Been Completed)
Father's Name

Tazkera Number

DS-4184

Tribe

Passport Number

Country of Issuance

Page 5 of 5
(See Addendum 1)