Download:
pdf |
pdfElectronic Form Version Number: 2.0
OMB APPROVAL NO. 1405-0013
EXPIRATION DATE: xx-xx-xxxx
*ESTIMATED BURDEN: 30 minutes
* PAPERWORK REDUCTION ACT STATEMENT: Public reporting burden for this collection of information is estimated to average 30 minutes 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: DDepartment of State, 2401 E St. NW, 12th Floor,
Washington, D.C. 20037
U.S. DEPARTMENT OF STATE
DIRECTORATE OF DEFENSE TRADE CONTROLS
APPLICATION/LICENSE FOR TEMPORARY IMPORT OF UNCLASSIFIED DEFENSE ARTICLES
*Transaction Number:
Please note that an Asterisk (*) next to a field in a document designate a mandatory field or block.
No classified information can be included in this application. Classified information must be sent
separately to PM/DDTC in accordance with the Defense Security Service guidelines.
Classified information is being sent under separate cover
To select and open a document, highlight a form and select the "Open Document" button. The document that you selected will open.
Required Documents
DSP-61
Optional Documents
22 CFR § 126.13 Certification Letter
22 CFR § 127.11 Exception to Policy Letter
Contract
Firearms and Ammunitions Import Permit
Firearms and Ammunitions Letter of Explanation
Letter of Intent
Manufacturer Unknown Letter of Explanation
Other Amplifying Data (e.g. Briefing, Proposals)
Precedent (identical/similar) Cases
Product Brochures
Purchase Order
Supplementary Explanation of Transaction (e.g. White Paper)
DSP-61
Included Documents
Errors
U.S. DEPARTMENT OF STATE
DIRECTORATE OF DEFENSE TRADE CONTROLS
By selecting the "Submit" button, above, the Applicant hereby warrants the truthfulness of
all statements made herein and in accompanying documentation; acknowledges and understands
that, in accordance with 22 C.F.R. §127.2, it is unlawful to use any export or temporary
import control document containing a false statement or misrepresenting or omitting a
material fact for the purpose of exporting any defense article or technical data or the
furnishing of any defense service for which a license or approval is required by this
subchapter and that any false statement, misrepresentation, or omission of material fact in
an export control or temporary import control document will be consider as made in a matter
within the jurisdiction of a department or agency of the United States for the purposes of
18 U.S.C. 1001, 22 U.S.C. 2778 and 22 U.S.C. 2779; and that the applicant further agrees to
comply with all applicable provisions of 22 C.F.R. §120-130.
To cancel this submission, select "Cancel".
(If you cancel the submission, you will return to the previous page.)
Please be further advised, that if the "Submit" button is not active and you have already saved the
submission, you may not have completed all of the required fields. As a reminder you must save the
submission before you can submit.
DSP-61, Page
1
of
4
SEAL
Signature
DATE ISSUED
License is hereby granted to the applicant for the described commodity to be shipped
to the United States in transit to indicated destination. This license may be revoked,
suspended or amended by the Secretary of State without prior notice whenever the
Secretary deems such action advisable.
LICENSE VALID FOR
LICENSE NO.
MONTHS FROM ABOVE DATE
UNITED STATES OF AMERICA
DEPARTMENT OF STATE
APPLICATION/LICENSE FOR TEMPORARY IMPORT OF UNCLASSIFIED DEFENSE ARTICLES
* 2. PM/DDTC
* 3. Foreign country from which shipped:
Applicant/Registrant
*1. Date prepared Code
03/18/2008
* 4. U.S. port of import
* 5. Foreign Country of Ultimate Destination:
7. Name, agency and telephone number of U.S. Government
personnel (not PM/DDTC) familiar with the commodity
* 6. U.S. port of export
8. Applicant's Name, Address, ZIP Code, and Telephone Number
*Applicant is:
Name
Manufacturer
Exporter
Government
Subsidiary
Agency
*Name
Telephone #
Ext.
*Attention
9. Name and telephone numbers of applicant contact if U.S.
Government needs additional information
*Address
*Name
*City
Ext.
*Telephone #
*State
Add
*ZIP Code
Ext.
*Telephone #
10. Description of Transaction
A.
The identical commodity was licensed to the country in Block 3 under license number(s).
B.
The identical commodity was licensed to other countries under license number(s).
C.
The identical commodity was denied to the country in Block 5 under voided license number(s).
D.
The identical commodity was never licensed for this applicant.
E.
This transaction is in furtherance of agreement number(s).
F.
The transaction is in support of agreement number(s).
* G. This application is related to a disclosure filed with Defense Trade Controls Compliance
No
Yes
Enter Compliance Disclosure Number:
Line
Item
#
*11. Quantity
*12a. Commodity
*12b.
*12c.
The commodity is a
Identify the commodity for which it is intended
None
Unit Type
1
*14. Value
Unit Price
*13. USML Cat. Number
Category
Sub
Add
Line Item Total
Commodity Code
*15. TOTAL VALUE (Sum of All Pages) $
0
DSP-61, Page
16.
Name and address of owner/end-user of commodity in
foreign country from which shipped
2
of
4
Manufacturer of Commodity
17.
Same as Block 8
*Name
*Name
*Address
*Address
*City
*City
*Country
State
Unknown
ZIP Code
*Country
Add
18.
Name and address of consignor in foreign country from
which shipped
19.
Source of Commodity
Same as Block 8
*Name
*Name
*Address
*Address
*City
*City
*Country
State
Same as Block 17
ZIP Code
*Country
Add
Add
20.
Name and address of foreign intermediate consignee
21.
Name and address of U.S. intermediate consignee
None
Same as Block 8
*Name
*Name
*Address
*Address
*City
*City
*Country
*State
Add
Add
Name and address of consignee in foreign country of ultimate
destination
22.
*ZIP Code
*23. Specific purpose for which the article or hardware is
temporarily imported
None
a.
*Name
Select all that apply:
Overhaul/Repair
Modification/Upgrade
Other (Provide Details)
*Address
*City
*Country
Add
24.
Name and address of end user in foreign country of ultimate
destination
Same as Block 16
*Name
*Address
*City
*Country
b.
Return to country in Block 16
Transshipment to third country
DSP-61, Page
3
of
*25. Applicant's Statement
I
an empowered official, (22 CFR §120.25) or an official of a foreign government entity in the U.S., hereby apply for a license to complete the transaction
described above; warrant the truth of all statements made herein; and acknowledge, understand and will comply with the provisions of 22 CFR, 120-130,
and any conditions and limitations imposed. If the commodity is firearm or ammunition of U.S. manufacture, I certify that, based on corroborative
evidence, the commodity was not furnished on a grant basis to, or acquired without full payment by, a foreign government under a foreign assistance
program of the U.S. as set forth in 27 CFR § 447.57.
I am authorized by the applicant to certify the following in compliance with 22 CFR § 126.13:
(1) Neither applicant, its chief executive officer, president, vice presidents, other senior officers or officials (e.g., comptroller, treasurer, general
counsel) nor any member of its board of directors is:
(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 Stat. 729 (June 30, 1976); or
(b) 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 from any agency of the U.S. Government;
(2) To the best of the applicant's knowledge, no party to the export as defined in 22 CFR § 126.7 (e) 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
Stat. 729 (June 30, 1976), or is 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 from any agency of the U.S. Government; and
* 22 CFR § 126.13 Certification (Select one)
a. I am authorized by the applicant to certify that the applicant and all of the parties to the transaction can meet in full the conditions of 22 CFR
§ 126.13 as listed above.
b. I am authorized by the applicant to certify to 22 CFR § 126.13. The applicant or one of the parties of the transaction cannot meet one or
more of the conditions of 22 CFR § 126.13 as listed above. A request for an exception to policy, as described in Section 127.11 of the ITAR, is
attached.
c. I am authorized by the applicant to certify to 22 CFR § 126.13. The applicant or one of the parties of the transaction cannot meet one or
more of the conditions of 22 CFR § 126.13 as listed above. However that party has met the conditions imposed by the Directorate of Defense
Trade Controls in order to resume standard submission of applications, not requiring an exception to policy as described in Section 127.11 of the
ITAR.
d. I am not authorized by the applicant to certify the conditions of 22 CFR § 126.13 as listed above. The applicant and all of the parties to the
transaction can meet in full the conditions of 22 CFR § 126.13 as listed above. Please see the attached letter from an official that is authorized
by the applicant to certify to the conditions of 22 CFR § 126.13.
e. I am not authorized by the applicant to certify the conditions of 22 CFR § 126.13 as listed above. The applicant or one of the parties of the
transaction cannot meet one or more of the conditions of 22 CFR § 126.13 as listed above. A request for an exception to policy, as described
in Section 127.11 of the ITAR, and a letter from an official that is authorized by the applicant to certify to the conditions of 22 CFR § 126.13
are attached.
f. I am not authorized by the applicant to certify the conditions of 22 CFR § 126.13 as listed above. The applicant or one of the parties of the
transaction cannot meet one or more of the conditions of 22 CFR § 126.13 as listed above. However that party has met the conditions imposed
by the Directorate of Defense Trade Controls in order to resume standard submission of applications, not requiring an exception to policy as
described in Section 127.11 of the ITAR. Please see the attached letter from an official that is authorized by the applicant to certify to the
conditions of 22 CFR § 126.13.
Signature
Signature
26. License to be sent to:
[Block is inactive on electronic form.]
Name
Address
City
State
Telephone #
ZIP Code
4
DSP-61, Page 4
of
4
CONDITIONS OF ISSUANCE AND TEMPORARY IMPORT PROCEDURES
1. This license is issued under the conditions cited in 22 CFR 120-130, including provisos as applicable to the specific license authorization.
2. Approval of this license shall not be construed as implying U.S. Government approval or commitment to authorize future temporary imports or exports of any
defense article on the U.S. Munitions List (USML) or any U.S. Government commitment with regard to any proposed manufacturing license, technical
assistance or distribution agreement that may result from a license authorization.
3. If a license is issued for temporary import of hardware, for return to the country of origin or in-transit to another foreign country, it does not authorize the
temporary import or export (permanent or temporary) from the United States of any technical data, unless covered by an exemption.
4. The issuance of this license does not release the applicant, or anyone acting on its behalf, from complying with other requirement of U.S. law and
regulations.
5. No transfer of title is authorized to occur during the period of temporary import for purposes of overhaul/repair or modification/upgrade into the United States
and access to the defense article by foreign persons shall only be in accordance with and for the purpose identified on the license.
6. Licenses for the temporary import of an aircraft or vessel: The applicant when using this license agrees that during its temporary import (1) the
aircraft/vessel will remain demilitarized unless otherwise authorized or will have only those capabilities that are the subject of the license; and (2) the applicant
will maintain the same certification or registry of entry. Also, the aircraft/vessel during its temporary import cannot be used in any activities (e.g., military
activities and transport of USML articles) that are not authorized in this license or by a separate license or exemption under appropriate USG regulations.
7. The prior written approval of the Department of State, Directorate of Defense Trade Controls, must be obtained before USML articles exported from the
United States using a license or other approval, to include an ITAR exemption, may be resold, transferred, diverted, transshipped, reshipped, re-exported to, or
used in any country, or by any end user or for any end use, other than that described on the license or other approval.
8. The defense articles authorized for temporary import may only be shipped temporarily into the United States using a Port where a U.S. Customs and Border
Protection officer is available. Shipments of defense articles licensed in accordance with the ITAR may not be shipped on a vessel, aircraft, or other means of
conveyance that is owned or operated by, or leased to or from, any of the proscribed countries or areas. Prior to any temporary import and subsequent export,
the exporter must present the original of the license to a U.S. Customs and Border Protection officer for verification, endorsement and retention and declare the
export or entry in accordance with the ITAR and U.S. Customs and Border Protection procedures using the Automated Export System (AES). Any article
temporarily imported must be exported to the authorized foreign destination prior to the expiration of the license. Otherwise, the applicant must submit a
renewal license at least 60 days prior to the expiration date to renew the authorization.
RETURN OF LICENSE
This license must be returned in accordance with 22 CFR 123 to PM/DDTC, SA-1, 12th Floor, Directorate of Defense Trade Controls, Bureau of
Political-Military Affairs, U.S. Department of State, Washington, D.C. 20522-0112 when: (1) the total value authorized has been shipped; (2) the applicant states
that there will be no further shipments; (3) the date of expiration is reached; or (4) when requested by the Directorate of Defense Trade Controls.
ENDORSEMENT
Indicate below which ITEM on the face of the license is BEING EXPORTED and maintain a CONTINUING BALANCE of the remaining value:
SHIPMENT
DATE
QUANTITY
COMMODITY
SHIPMENT
VALUE
SED NO.
INITIALS
PORT OF
EXIT/ENTRY
TOTAL AUTHORIZED VALUE:
REMAINING BALANCE:
NOTE Continuation of additional shipments must be authenticated by use of continuation sheets in the U.S.Customs handbook.
DSP-61, Page
Subsidiary Information under Block 8, Page 1 of the DSP-61
*Name
*Attention
*Address
*City
*State
*Telephone #
*ZIP Code
Ext
of
4
Additional Contacts Information
of
DSP-61 Page
0
Additional Applicant Contact Information
Name
Telephone #
Name
Ext
Name
Telephone #
Ext
Ext
Ext
Ext
Ext
Ext
Telephone #
Ext
Telephone #
Ext
Telephone #
Ext
Telephone #
Ext
Name
Ext
Name
Telephone #
Ext
Name
Name
Telephone #
Telephone #
Name
Name
Telephone #
Ext
Name
Ext
Name
Telephone #
Telephone #
Name
Name
Telephone #
Ext
Name
Name
Telephone #
Telephone #
Name
Name
Telephone #
Ext
Name
Name
Telephone #
Telephone #
Telephone #
Ext
Name
Ext
Telephone #
Ext
of
4
Description of Transaction
Continuation to Block 10
The identical commodity was licensed to the country in Block 3 of the first page under license no(s).
The identical commodity was licensed to other countries under license no(s).
The identical commodity was denied to the country in Block 5 of the first page under voided license(s).
The transaction is in furtherance of agreement no(s).
The transaction is in support of agreement no(s).
DSP-61, Page
of
4
Additional Commodities Page
Line 11. Quantity
Item
#
-1
of
12a. Commodity
0
Identify the commodity for which it is intended
Sub
11. Quantity
12a. Commodity
Line Item Total
12b.
The commodity is a
12c.
Identify the commodity for which it is intended
None
Sub
14. Value
Unit Price
Line Item Total
Commodity Code
12a. Commodity
12b.
12c.
The commodity is a
Identify the commodity for which it is intended
None
Unit Type
13. USML Cat. Number
Category
Unit Price
Commodity Code
Unit Type
Category
1
12c.
14. Value
13. USML Cat. Number
Line
Item
#
The commodity is a
4
None
Category
11. Quantity
of
12b.
Unit Type
13. USML Cat. Number
Line
Item
#
DSP-61, Page
Additional Commodities
0
Sub
14. Value
Unit Price
Line Item Total
Commodity Code
TOTAL VALUE (This Page)
$
0
Additional Manufacturers Page #
of
0
DSP-61, Page
Additional Manufacturers of Commodities
Name
Name
Address
Address
City
City
State
ZIP Code
State
Country
Country
Name
Name
Address
Address
City
City
State
ZIP Code
State
Country
Country
Name
Name
Address
Address
City
City
State
ZIP Code
State
Country
Country
Name
Name
Address
Address
City
City
State
ZIP Code
State
Country
Country
Name
Name
Address
Address
City
City
State
Country
ZIP Code
State
Country
ZIP Code
ZIP Code
ZIP Code
ZIP Code
ZIP Code
of
4
Additional Sources Page #
of
0
Additional Sources of Commodities
Name
Name
Address
Address
City
City
State
ZIP Code
State
Country
Country
Name
Name
Address
Address
City
City
State
ZIP Code
State
Country
Country
Name
Name
Address
Address
City
City
State
ZIP Code
State
Country
Country
Name
Name
Address
Address
City
City
State
ZIP Code
State
Country
Country
Name
Name
Address
Address
City
City
State
Country
ZIP Code
State
Country
DSP-61, Page
ZIP Code
ZIP Code
ZIP Code
ZIP Code
ZIP Code
of
4
Additional Foreign Consignor Page #
of
0
DSP-61, Page
Additional Foreign Consignors
Name
Name
Address
Address
City
City
Country
Country
Name
Name
Address
Address
City
City
Country
Country
Name
Name
Address
Address
City
City
Country
Country
Name
Name
Address
Address
City
City
Country
Country
Name
Name
Address
Address
City
City
Country
Country
Name
Name
Address
Address
City
City
Country
Country
of
4
Additional Intermediate
Consignees Page #
of
0
DSP-61, Page
Additional Intermediate Consignees in United States
Name
Name
Address
Address
City
City
State
ZIP Code
State
Name
Name
Address
Address
City
City
State
ZIP Code
State
Name
Name
Address
Address
City
City
State
ZIP Code
State
Name
Name
Address
Address
City
City
State
ZIP Code
State
Name
Name
Address
Address
City
City
State
ZIP Code
State
Name
Name
Address
Address
City
City
State
ZIP Code
State
ZIP Code
ZIP Code
ZIP Code
ZIP Code
ZIP Code
ZIP Code
of
4
Additional Foreign Intermediate
Consignees Page #
0
of
Additional Foreign Intermediate Consignees
Name
Name
Address
Address
City
City
Country
Country
Name
Name
Address
Address
City
City
Country
Country
Name
Name
Address
Address
City
City
Country
Country
Name
Name
Address
Address
City
City
Country
Country
Name
Name
Address
Address
City
City
Country
Country
Name
Name
Address
Address
City
City
Country
Country
DSP-61, Page
of
4
Additional Foreign Country of
Ultimate Destination Page #
of
0
Additional Consignees in Foreign
Country of Ultimate Destination
Name
Name
Address
Address
City
City
Country
Country
Name
Name
Address
Address
City
City
Country
Country
Name
Name
Address
Address
City
City
Country
Country
Name
Name
Address
Address
City
City
Country
Country
Name
Name
Address
Address
City
City
Country
Country
Name
Name
Address
Address
City
City
Country
Country
DSP-61, Page
of
4
Attachments Pertaining to the Letter of Intent
Attachment?:
Add Attachments
Preferred attachment file type is PDF searchable.
Remove Attachments
View Attachments
Attachments Pertaining to Manufacturer Unknown Letter of Explanation
Attachment?:
Add Attachments
Preferred attachment file type is PDF searchable.
Remove Attachments
View Attachments
Attachments Pertaining to Purchase Orders
Attachment?:
Add Attachments
Preferred attachment file type is PDF searchable.
Remove Attachments
View Attachments
Attachments Pertaining to Contracts
Attachment?:
Add Attachments
Preferred attachment file type is PDF searchable.
Remove Attachments
View Attachments
Attachments pertaining to Other Amplifying Data (e.g. Briefings, Proposals)
Attachment?:
Add Attachments
Preferred attachment file type is PDF searchable.
Remove Attachments
View Attachments
Attachments pertaining to Precedent (identical/similar) Cases
Attachment?:
Add Attachments
Preferred attachment file type is PDF searchable.
Remove Attachments
View Attachments
Attachments pertaining to Product Brochures
Attachment?:
Add Attachments
Preferred attachment file type is PDF searchable.
Remove Attachments
View Attachments
Attachments pertaining to Supplementary Explanation of Transportation (e.g. White Paper)
Attachment?:
Add Attachments
Preferred attachment file type is PDF searchable.
Remove Attachments
View Attachments
Attachments pertaining to 22 CFR § 127.11 Exception to Policy Letter
Attachment?:
Add Attachments
Preferred attachment file type is PDF searchable.
Remove Attachments
View Attachments
Attachments pertaining to 22 CFR § 126.13 Certification Letter
Attachment?:
Add Attachments
Preferred attachment file type is PDF searchable.
Remove Attachments
View Attachments
Attachments pertaining to Firearms and Ammunitions Import Permit
Attachment?:
Add Attachments
Preferred attachment file type is PDF searchable.
Remove Attachments
View Attachments
Attachments pertaining to Firearms and Ammunitions Letter of Explanation
Attachment?:
Add Attachments
Preferred attachment file type is PDF searchable.
Remove Attachments
View Attachments
Are you sure you want to delete this page?
To continue and delete selection, select "YES". To cancel delete, select "NO".
After the page has been deleted, you will be automatically returned to the previous continuation
page (if you have 2 or more continuation pages) or to the main page for the Block for which the
additional page was added (if you have only one continuation page).
YES
NO
| File Type | application/pdf |
| File Title | H:\Documents\sample_dsp-61_v2.0.xfdl |
| Author | lunsfordtr |
| File Modified | 2015-02-02 |
| File Created | 2008-03-18 |