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pdfOMB APPROVAL NO. 1405-0204
EXPIRES: 4/30/2015
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
Cell Phone Number
Fax Number
E-mail Address
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
05-2012
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 current 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: U.S. Dept. of State, 2201 C St. NW, SA-15 room 3200,
Washington, DC 20520.
PRIVACY ACT STATEMENT
Authority: 18 U.S.C. 2339A, 2339B, 2339C, 22 U.S.C. 2151 et seq., 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 on this form may be shared with the United States Agency for International Development (USAID) and with federal
government agencies for vetting programs. More information on the Routine Uses for the system can be found in the System of Records Notice State
(See Addendum 1)
Disclosure: Providing this information is voluntary, but failure to provide it might result in denial of your application.
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)
U.S. citizen or Permanent Legal Resident?
Yes
Female
No
If yes, provide Social Security Number and/or U.S. Passport Number
Government Issued Photo ID Type
Government Issued Photo ID Number
Address
Current Employer
Country of Issuance
Phone Number
Cell Phone Number
Skype Address
E-mail Address
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 2 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)
U.S. citizen or Permanent Legal Resident?
Yes
Female
No
If yes, provide Social Security Number and/or U.S. Passport Number
Government Issued Photo ID Type
Government Issued Photo ID Number
Address
Current Employer
Country of Issuance
Phone Number
Cell Phone Number
Skype 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)
U.S. citizen or Permanent Legal Resident?
Yes
Female
No
If yes, provide Social Security Number and/or U.S. Passport Number
Government Issued Photo ID Type
Government Issued Photo ID Number
Address
Current Employer
Country of Issuance
Phone Number
Cell Phone Number
Skpye 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)
U.S. citizen or Permanent Legal Resident?
Yes
Female
No
If yes, provide Social Security Number and/or U.S. Passport Number
Government Issued Photo ID Type
Government Issued Photo ID Number
Address
Current Employer
Country of Issuance
Phone Number
Cell Phone Number
Skype 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)
U.S. citizen or Permanent Legal Resident?
Yes
Female
No
If yes, provide Social Security Number and/or U.S. Passport Number
Government Issued Photo ID Type
Government Issued Photo ID Number
Address
Current Employer
Country of Issuance
Phone Number
Cell Phone Number
Skype 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)
U.S. citizen or Permanent Legal Resident?
Yes
Female
No
If yes, provide Social Security Number and/or U.S. Passport Number
Government Issued Photo ID Type
Government Issued Photo ID Number
Address
Current Employer
Country of Issuance
Phone Number
Cell Phone Number
Skype 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)
U.S. citizen or Permanent Legal Resident?
Yes
Female
No
If yes, provide Social Security Number and/or U.S. Passport Number
Government Issued Photo ID Type
Government Issued Photo ID Number
Address
Current Employer
Country of Issuance
Phone Number
Cell Phone Number
Skype 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
| File Type | application/pdf |
| File Title | DS-4184 |
| Author | deckardmc |
| File Modified | 2015-04-24 |
| File Created | 2015-04-24 |