CFIUS Declaration Declaration Submission Form for Critical Technology Pilo

OMB Control No. 1505-0121, Expiration Date: 06/30/2019
U.S. DEPARTMENT OF THE TREASURY

Declaration Submission Form for Critical Technology Pilot Program
to the Committee on Foreign Investment in the United States

IMPORTANT: All fields on this form are required unless otherwise explicitly noted.
1. List of all parties to this transaction and, if not directly a party to the transaction, the pilot
program U.S. business that is the subject of this declaration (300 max. character count):

2. Are all parties to this transaction submitting this declaration jointly?

Yes

No

Yes

No

3. For the pilot program U.S. business:
a. Business name:
b. Primary point of contact name:
c. Phone:
d. Primary email:
e. Secondary contact email (optional):
4. For the foreign person:
a. Business or person name:
b. Primary point of contact name:
c. Phone:
d. Primary email:
e. Secondary contact email (optional):
5. Structure of transaction:
6. Percentage of voting interest acquired:

0.00%

7. Percentage of economic interest acquired:

0.00%

8. Does the pilot program U.S. business have multiple classes of ownership?
9. Total transaction value in U.S. dollars:
10. Expected closing date:

PAPERWORK REDUCTION ACT NOTICE
The information collected will be used for the U.S. Government to assess the effects of the transaction in question to the national
security of the United States pursuant to authorities under Section 721 of the Defense Production Act of 1950, as amended. We
estimate that it will take an average of 20 hours to complete each declaration. Comments concerning the accuracy of this burden
estimate and suggestions for reducing this burden should be directed to the Office of Privacy, Transparency and Records,
Department of the Treasury, 1500 Pennsylvania Ave., N.W., Washington, D.C. 20220. An agency may not conduct or sponsor,
and a person is not required to respond to, a collection of information unless it displays a valid control number assigned by OMB.
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11. Description of the transaction (3750 max. character count):

12. Sources of financing for the transaction (950 max. character count):

13. Do the parties stipulate that the transaction is a pilot program covered
transaction?

Yes

No

14. Do the parties stipulate that the transaction could result in control of a pilot
program U.S. business by a foreign person?

Yes

No

15. Do the parties stipulate that the transaction is a foreign governmentcontrolled transaction?

Yes

No

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16. Description of the basis for any affirmative stipulations for Questions 13 – 15 (1800 max.
character count):

17. Will the foreign person acquire any of the following in the pilot program U.S. business:
a. Access to material nonpublic technical information as set forth in §801.209(a)?

Yes

No

b. Membership, observer rights, or nomination rights as set forth in §801.209(b)?

Yes

No

c. Any involvement in substantive decisionmaking as set forth in §801.209(c)?

Yes

No

d. Any rights that could result in the foreign person acquiring control?

Yes

No

18. Explanation for any affirmative responses to Question 17 or, if there are no affirmative
responses, for why the parties are submitting a declaration (1400 max. character count):

19. Information regarding the pilot program U.S. business:
a. Website address:
b. Place of incorporation or organization (state/province, country):
c. Physical address of its principal place of business:
d. Physical address of its headquarters:
e. Attach here a list of the addresses or geographic coordinates (to at least the fourth decimal) of all
locations of the pilot program U.S. business, including the pilot program U.S. business’s
headquarters, facilities, and operating locations, to the extent not already provided above.
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20. Summary of the business activities of the pilot program U.S. business as set forth in §801.403(c)(6)
(3400 max. character count):

21. Statement of all critical technologies the pilot program U.S. business and its subsidiaries produce,
design, test, manufacture, fabricate, or develop, and the applicable NAICS code for each, as set forth
in §801.403(c)(7). If additional space is required, attach document here:
Name of Critical
Technology

Critical Technology
Classification

Six-Digit NAICS Code

22. Does the pilot program U.S. business have any contracts with any
U.S. Government agency or component as set forth in §801.403(c)(8)?

Yes

No

23. Does the pilot program U.S. business have any contracts involving
information, technology, or data as set forth in §801.403(c)(9)?

Yes

No

24. Has the pilot program U.S. business received any grant or other funding or
participated in or collaborated on a program or product as set forth in
§801.403(c)(10)?

Yes

No

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25. Has the pilot program U.S. business participated in a Defense
Production Act Title III Program within the past seven years?

Yes

No

26. Has the pilot program U.S. business received or placed any priority rated
contracts or orders under the Defense Priorities and Allocations Systems
(DPAS) regulations within the past three years?

Yes

No

Yes

No

Yes

No

Yes

No

27. If Question 26 is answered affirmatively, the level(s) of priority of such
contracts or orders (DX or DO):
28. Name of the ultimate parent of the foreign person:
29. Attach here a complete organizational chart as set forth in §801.403(c)(14).
30. Does any foreign government or foreign-government owned entity have
any ownership interest, directly or indirectly, or any rights, directly or indirectly,
in the foreign person?
31. If so, attach here an explanation of all such ownership interests and rights,
including the nationalit(ies) and percentage(s) of ownership.
32. Summary of the business activities of the foreign person that is party to the
transaction as set forth in §801.403(c)(16) (1300 max. character count):

33. Has any party to the transaction been party to another transaction
previously notified or submitted to the Committee?
34. If so, provide the case number assigned by the Committee regarding such
transaction(s):
35. Has the pilot program U.S. business, the foreign person, or any parent or
subsidiary of the foreign person been convicted of a crime in any jurisdiction
within the past ten years?
36. If so, provide a brief statement, including relevant jurisdiction and criminal
case law number or legal citation (300 max. character count):

37. Do the parties certify that the information contained in the declaration is
consistent with §800.202?
38. Attach certifications here.
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Yes