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pdfSigning Instructions
OMB APPROVAL NO. 1405-0204
EXPIRES: XX/XX/20XX
ESTIMATED BURDEN: 90 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: SYRIA
Is this work performed for Syria?
Yes
No
PART 4: 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)
Signature
Title/Organization
Date (mm-dd-yyyy)
(User Name)
DS-4184
08-2018
Page 1 of 8
KEY INDIVIDUAL INFORMATION
Name (Last, First, MI)
Other Names Used ("Also known as", nicknames, alias, different spelling)
Place of Birth (City, State, Province, Country)
Date of Birth (mm-dd-yyyy)
Gender:
Male
Citizenship(s)
U.S. 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
Cell Phone Number
Skype Address / WhatsApp
E-mail Address
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
Additional Information Required for Defected Regime Personnel Only:
Previous Syrian Arab Republic Government (SARG) Ministry and Unit
Previous Position (Rank/Title)
Description of Duties
Time Served (mm/yyyy to mm/yyyy)
to
Location of Previous Unit (Province, City/Municipality/Town, neighborhood, facility and station, Country)
DS-4184
Page 2 of 8
KEY INDIVIDUAL INFORMATION
Name (Last, First, MI)
Other Names Used ("Also known as", nicknames, alias, different spelling)
Place of Birth (City, State, Province, Country)
Date of Birth (mm-dd-yyyy)
Gender:
Male
Citizenship(s)
U.S. 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
Cell Phone Number
Skype Address / WhatsApp
E-mail Address
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
Additional Information Required for Defected Regime Personnel Only:
Previous Syrian Arab Republic Government (SARG) Ministry and Unit
Previous Position (Rank/Title)
Description of Duties
Time Served (mm/yyyy to mm/yyyy)
to
Location of Previous Unit (Province, City/Municipality/Town, neighborhood, facility and station, Country)
DS-4184
Page 3 of 8
KEY INDIVIDUAL INFORMATION
Name (Last, First, MI)
Other Names Used ("Also known as", nicknames, alias, different spelling)
Place of Birth (City, State, Province, Country)
Date of Birth (mm-dd-yyyy)
Gender:
Male
Citizenship(s)
U.S. 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
Cell Phone Number
Skype Address / WhatsApp
E-mail Address
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
Additional Information Required for Defected Regime Personnel Only:
Previous Syrian Arab Republic Government (SARG) Ministry and Unit
Previous Position (Rank/Title)
Description of Duties
Time Served (mm/yyyy to mm/yyyy)
to
Location of Previous Unit (Province, City/Municipality/Town, neighborhood, facility and station, Country)
DS-4184
Page 4 of 8
KEY INDIVIDUAL INFORMATION
Name (Last, First, MI)
Other Names Used ("Also known as", nicknames, alias, different spelling)
Place of Birth (City, State, Province, Country)
Date of Birth (mm-dd-yyyy)
Gender:
Male
Citizenship(s)
U.S. 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
Cell Phone Number
Skype Address / WhatsApp
E-mail Address
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
Additional Information Required for Defected Regime Personnel Only:
Previous Syrian Arab Republic Government (SARG) Ministry and Unit
Previous Position (Rank/Title)
Description of Duties
Time Served (mm/yyyy to mm/yyyy)
to
Location of Previous Unit (Province, City/Municipality/Town, neighborhood, facility and station, Country)
DS-4184
Page 5 of 8
KEY INDIVIDUAL INFORMATION
Name (Last, First, MI)
Other Names Used ("Also known as", nicknames, alias, different spelling)
Place of Birth (City, State, Province, Country)
Date of Birth (mm-dd-yyyy)
Gender:
Male
Citizenship(s)
U.S. 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
Cell Phone Number
Skype Address / WhatsApp
E-mail Address
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
Additional Information Required for Defected Regime Personnel Only:
Previous Syrian Arab Republic Government (SARG) Ministry and Unit
Previous Position (Rank/Title)
Description of Duties
Time Served (mm/yyyy to mm/yyyy)
to
Location of Previous Unit (Province, City/Municipality/Town, neighborhood, facility and station, Country)
DS-4184
Page 6 of 8
KEY INDIVIDUAL INFORMATION
Name (Last, First, MI)
Other Names Used ("Also known as", nicknames, alias, different spelling)
Place of Birth (City, State, Province, Country)
Date of Birth (mm-dd-yyyy)
Gender:
Male
Citizenship(s)
U.S. 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
Cell Phone Number
Skype Address / WhatsApp
E-mail Address
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
Additional Information Required for Defected Regime Personnel Only:
Previous Syrian Arab Republic Government (SARG) Ministry and Unit
Previous Position (Rank/Title)
Description of Duties
Time Served (mm/yyyy to mm/yyyy)
to
Location of Previous Unit (Province, City/Municipality/Town, neighborhood, facility and station, Country)
DS-4184
Page 7 of 8
PAPERWORK REDUCTION ACT STATEMENT
*Public reporting burden for this collection of information is estimated to average 90 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., 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) and other U.S. Government agencies 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) (State 78) 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).
DS-4184
Page 8 of 8
| File Type | application/pdf |
| File Title | DS-4184 |
| Author | PeckhamYM |
| File Modified | 2019-02-28 |
| File Created | 2019-02-28 |