Disclosure of Information related to Potential Violations

OMB APPROVAL NO. ####-#### EXPIRATION DATE: XX/XX/XXXX

U.S. Department of State

Instructions for Preparing and Submitting a

DS-7787: Disclosure of Information to the Office of Defense Trade Controls Compliance

GENERAL INSTRUCTIONS

1. Do not enter classified information on the form or upload documents containing classified information as part of this submission. Instead, follow Directorate of Defense Trade Controls (DDTC) guidelines for the submission of classified information.

2. The International Traffic in Arms Regulations (ITAR) encourages disclosures by persons who believe they may have violated an export control provision of the Arms Export Control Act (AECA), or any regulation, order, license, or other authorization issued thereunder. This form is intended to be used to disclose both potential and actual violations. Any terminology in form DS-7787 or these instructions that refers to a violation is intended to capture both potential and actual violations. Activities constituting a violation are described in the ITAR. If, after a full investigation, the occurrence of an actual violation cannot be confirmed, the disclosure of any potential violations is still encouraged and should describe the investigation efforts undertaken and the reasons why a determination of whether a violation actually occurred could not be made.

3. This form facilitates the capture of information as required in Section 127.12 of the ITAR. If the form does not allow for the full disclosure of information, submitters may provide a summary of the requested information. If providing a summary, submitters should provide complete information by uploading a document in Block 5 by choosing “Voluntary Disclosure Narrative” for Document Type.

4. Submit copies of documents substantiating the claims in the disclosure. Block 5 allows submitters to upload several different types of supporting documents. If a document doesn’t fall under one of the existing types, select “Other” for Document Type and describe the type of document in the space provided.

5. If the volume or size of the supporting documentation to be included with the submission warrants sending the documents to the Office of Defense Trade Controls Compliance (DTCC) separately from the electronic submission, a Table of Contents for the supporting documents must be uploaded with the online submission. When doing so, the submitter should select “Other” for Document Type and enter “Table of Contents” in the space provided. The Table of Contents must specify the documents being provided separately, the type of each document, and sufficient information about each document to enable DTCC to easily identify the document.

6. There are several fields throughout the form that allow for additional responses to be provided (e.g. ITAR Section Violated). These fields are indicated by an Add button that appears next to the field. Selecting the Add button will provide a field for the additional response.

BLOCK 1. IDENTIFYING INFORMATION

Provide the following identifying information about the natural person or entity submitting the disclosure.

Registered with DDTC

Indicate whether the submitter is registered with DDTC. (REQUIRED)

Registration Code

If Registered with DDTC is “Yes,” enter the registration code you received upon registering with DDTC. If the submitter has multiple registration codes, provide the registration codes most relevant to the disclosure.

Organization Type

Select the submitter’s organization type (REQUIRED)

Corporation	Select when the submitter is a corporation.
Limited Liability Company	Select when the submitter is a limited liability company.
Partnership	Select when the submitter is a partnership.
Sole Proprietorship	Select when the submitter is a sole proprietorship.
Educational Institution	Select when the submitter is a university, college, vocational school or other post secondary educational institution.
Individual	Select when the submitter is a natural person acting in his or her personal capacity. If the submitter is an individual acting or agent on behalf of another legal entity or sole proprietorship, “Individual” should not be selected.
Other	Select if none of the other organization types apply.

Non Profit?

Select Yes when the submitter is a nonprofit.

Submitter Identifying Information

Indicate whether the disclosure is being submitted by a natural person or an entity. If the submitter is acting in his or her personal capacity, select “Natural Person.” If the submission is being made on behalf of a corporation, business association, partnership, society, trust, or any other entity, organization or group, including governmental entities; select “Entity.” (REQUIRED)

First Name

If Submitter Identifying Information Type is “Natural Person,” enter the legal first name of the submitter. (REQUIRED)

Middle Name

If Submitter Identifying Information Type is “Natural Person,” enter the legal middle name of the submitter. If the submitter does not have a legal middle name, select None.

Last Name

If Submitter Identifying Information Type is “Natural Person,” enter the legal last name of the submitter. (REQUIRED)

Company or Organization

If Submitter Identifying Information Type is “Entity,” enter the legal name of the company or organization making the submission. Enter the parent entity information, submitters will have the opportunity to identify applicable subsidiaries on page 2. (REQUIRED)

Doing Business as Name

If Submitter Identifying Information Type is “Entity,” and if the entity’s operating name is different from the legal name, enter the operating name of the company or organization. (OPTIONAL)

Address Line 1

Enter the first line of the submitter’s street address. (REQUIRED)

Address Line 2

Enter the second line of the submitter’s street address.

Address Line 3

Enter the third line of the submitter’s street address.

City

Enter the name of the city where the submitter’s street address is located. (REQUIRED)

Country

Select the name of the country where the submitter’s street address is located. (REQUIRED)

State/Province

Enter the name of the state or province where the submitter’s street address is located.

ZIP/Postal Code

Enter the ZIP or postal code where the submitter’s street address is located.

Website

Enter the web address of the submitter’s website.

Affiliate/ Subsidiary Ownership/ Control

Indicate whether the submitter owns, or otherwise controls, any U.S. or foreign affiliates or subsidiaries that are involved in this disclosure of information to DTCC. To include additional affiliates or subsidiaries involved in this disclosure, select Add. (REQUIRED)

Affiliate/ Subsidiary

If Affiliate/Subsidiary Ownership/Control is “Yes,” provide the following information for each affiliate or subsidiary controlled by the submitter that are involved in this disclosure of information to DDTC.

Company or Organization	Enter the legal name of the Affiliate/Subsidiary company or organization making the submission. (REQUIRED)
Doing Business as Name	If the Affiliate/Subsidiary operating name is different from the legal name, enter the operating name of the company or organization. (OPTIONAL)
Address Line 1	Enter the first line of the Affiliate/Subsidiary’s street address. (REQUIRED)
Address Line 2	Enter the second line of the Affiliate/Subsidiary’s street address.
Address Line 3	Enter the third line of the Affiliate/Subsidiary’s street address.
City	Enter the name of the city where the Affiliate/Subsidiary street address is located. (REQUIRED)
Country	Select the name of the country where the Affiliate/Subsidiary street address is located. (REQUIRED)
State/Province	Enter the name of the state or province where the Affiliate/Subsidiary street address is located.
ZIP/Postal Code	Enter the ZIP or postal code where the Affiliate/Subsidiary street address is located.
Website	Enter the web address of the Affiliate/Subsidiary website.
Relationship	Specify if this is an subsidiary or affiliate as defined by Section 120.40 of the ITAR.
U.S. Person	Specify if the entity is a U.S. person as defined by Section 120.15 of the ITAR. (REQUIRED)

BLOCK 2. POINT OF CONTACT INFORMATION

Provide the point of contact information for the disclosure. At least one point of contact must be provided. The primary point of contact is not required to be an empowered official or senior officer. To include additional points of contact, select Add.

Name	Enter the name of a point of contact authorized to discuss the disclosure. (REQUIRED)
Telephone	Enter a telephone number where the point of contact can be reached.
E-Mail	Enter an e-mail address where the point of contact can be reached.
Point of Contact Type	Indicate whether the point of contact is the submitter or a third party. If the point of contact is a third party authorized to discuss the disclosure on behalf of the submitter (e.g. outside counsel), select “Third Party.” Otherwise, select “Submitter.” (REQUIRED)
Company or Organization	Enter the legal name of the point of contact’s company.
Address Line 1	Enter the first line of the point of contact’s street address.
Address Line 2	Enter the second line of the point of contact’s address.
Address Line 3	Enter the third line of the point of contact’s address.
City	Enter the name of the city where the point of contact’s address is located.
Country	Select the country where the point of contact’s address is located.
State/Province	Enter the state or province where the point of contact’s address is located.
ZIP/Postal Code	Enter the ZIP or Postal Code where the point of contact’s address is located.
Website	Enter the web address of the point of contact’s website.

BLOCK 3. DISCLOSURE INFORMATION

Select the option that best describes your submission (REQUIRED):

Submission Type	Initial Voluntary Disclosure The initial voluntary disclosure to DDTC following the discovery of a violation of any export control provision of the AECA, or any regulation, order, license, or other authorization issued under the authority of the AECA. Requires a Full Voluntary Disclosure within 60 calendar days unless an extension is sought and granted. Full Voluntary Disclosure The full disclosure to DDTC of a violation of any export control provision of the AECA, or any regulation, order, license, or other authorization issued under the authority of the AECA. The full disclosure should contain all information required by 22 CFR 127.12(c)(2), copies of substantiating documents, and a 127.12(e) certification statement from an empowered official or senior officer. Supplemental Information Additional information related to an existing disclosure case. For example, adding an involved party not previously disclosed or withdrawal of a disclosure. Note: The submission of supplemental information may not be used in place of the obligation to provide a full voluntary disclosure within 60 calendar days of an initial voluntary disclosure. Response to DTCC Inquiry The submission of information in response to an inquiry from DTCC. Extension Request A request for an extension of the 60 calendar day deadline for submitting a full voluntary disclosure following an initial voluntary disclosure; or a request for an extension for submitting response to an inquiry from DTCC. Notification Notfication types are 1) 126.1 Notification; 2) Third-Party Violation Notification; and 3) Other. Refer any third-party ITAR violations; immediately notify if any person knows or has reason to know of a proposed, final, or actual sale, export, transfer, reexport, or retransfer of articles, services, or data involving a proscribed country in ITAR Section 126.1; or notify any other compliance-related matters to DTCC. Other Only use this option if your submission type is not listed.
Disclosure Case Number	If DTCC has assigned a case number, enter it here. If DTCC has not assigned a case number, do not complete the field. If this is a completely new matter, you will not have a case number and do not populate this field.
Proposed Due Date	If Submission Type is “Extension Request” enter the requested deadline date for submitting the full voluntary disclosure or “Response to DTCC Inquiry.” (REQUIRED)
Explanation	If Submission Type is “Extension Request,” specify what information required by ITAR Section 127.12(c)(2) could not be provided by the current deadline and the reasons why. (REQUIRED)
Notification Type	If Submission Type is “Notification,” indicate the type of notification. (REQUIRED) 126.1 Notification A notification by any person who knows or has reason to know of a proposed, final or actual sale, export, reexport or retransfer of articles, services or data involving a 126.1 country. Third-Party A notification to refer or report violations committed Violation Notification by third parties. If the submitter is reporting a violation for which it was not responsible, select this Notification Type. Other Enter the type of notification in the space provided.
	If Submission Type is “Notification,” identify the entity or natural person that the Notification is concerning. If known, enter the complete identity and addresses, including the mailng, shipping, and e-mail addresses; telephone numbers and any other identifying information.
Purpose of Submission	If Submission Type is “Other,” you must explain the purpose for the provided information.

BLOCK 4. VIOLATION SUMMARY INFORMATION

Provide the following summary information about the violation.

Violation Start Date	If known, enter the earliest date the violation occurred. If multiple violations are included in the disclosure, the date should be the date of the earliest violation. If the precise date is unknown, enter the first day of the month or the first day of the year and explain why the precise date is unknown in the Description of and Circumtances Surrounding the Violation field.
Violation End Date	If known, enter the latest date the violation occurred. If multiple violations are included in the disclosure, the date should be the date of the latest violation. If all violations occurred on the same day, enter the same date for both Violation Start Date and Violation End Date. If the precise date is unknown, enter the first day of the month or the first day of the year and explain why the precise date is unknown in the Description of and Circumtances Surrounding the Violation field.
Description of and Circumstances Surrounding the Violation	Enter a precise description of the nature and extent of the violation and the circumstances surrounding the violation being disclosed. Explain who, when, where, how, and why the violation occurred, and how it was discovered.
ITAR Section Violated	Select the ITAR section violated. Select from the drop-down menu all of the relevant ITAR sections directly implicated in violations disclosed. To include multiple sections of the ITAR sections violated, select Add. Reflect the ITAR section violated at the time violation occurred.
Defense Article (including Technical Data) and/or Defense Service Description	Identify and describe the product, quantity, characteristics, and technological capabilities of the hardware, technical data, or defense service involved in the violation. If the disclosed violation involves failure to register, describe the type(s) of defense article manufactured, exported, temporarily imported or, brokered, or the defense service provided, for which registration is required.
USML Category	Select the U.S. Munitions List (USML) category and subcategory for the defense articles, technical data, or defense services (at the time the violation occurred) involved in the disclosed violation. To include additional USML categories, select Add. Do not include a USML category if the disclosed violation does not involve any hardware, technical data, or defense service on the USML (e.g., lapsed registration).
Significant Military Equipment Involved	Indicate whether significant military equipment (SME) was involved in the violation. (See ITAR Section 121.1(b)(3))
Classified Information Involved	Indicate whether classified information was involved in the violation.
Authorization Number	If applicable, enter any relevant Department of State authorization (including license, agreement, and/or general correspondence) numbers. To include additional relevant authorization numbers, select Add.
Exemption Citation	If applicable, enter any relevant Department of State exemption citations. If Exemption Citation is “Other,” enter a description of the relevant exemption in the space provided. To include additional citations, select Add.
Foreign Country/Foreign Person Nationality	Select from the drop-down menu all countries involved in the violation, including countries of origin for involved persons. Select “N/A” if violation does not involve a foreign country or person. To include additional foreign countries or nationalities of persons , select Add.
126.1 Country/National Involved	Select “yes” if the information submitted involves a country identified in ITAR Section 126.1, including foreign persons from such countries. If applicable, this response will satisfy the duty to notify DDTC described in ITAR Section 126.1(e).
Identities and Addresses of Persons Involved	Enter the complete identities and addresses of all persons known or suspected to be involved in the activities giving rise to the violations being disclosed. For each, include the mailng, shipping, and e-mail addresses; telephone numbers and any other identifying information. If relevant, include submitter’s subsidiaries, sub-licencees, or sub-contractors.
Root Cause of Violation	Describe the most significant underlying causes of the disclosed violation.
Corrective Actions	Describe the corrective actions already taken that clearly identifies the new compliance initatives implemented to address the causes of the disclosed violation, any disciplinary action taken, and how the actions are designed to deter and prevent the violation from occurring again. If applicable, include a description of proposed actions to be implemented along with a proposed timeline.
Related to Previous Disclosure	Identify the case numbers, if known, of previously submitted disclosures within the past five (5) years related to this disclosure. This may include disclosures with substantially similar circumstances such that prior corrective actions should have prevented the violation being disclosed in this submission; and disclosures with the same or related fact patterns.
Disclosure Case Number	If Related to Previous Disclosure is “Yes,” enter the related disclosure case number. To include additional related cases, select Add.

BLOCK 5. RELEVANT DOCUMENTS

To include relevant documents with the submission, select the file to be included and indicate the Document Type. All document types listed are optional, except when submitting a full disclosure, the document type, “Empowered Official/Senior Officer Certification” is required. Click Upload and repeat for each relevant document to be included with the submission. The document types are described below:

Voluntary Disclosure Narrative	If applicable, a narrative response to comply fully with the requirements of ITAR Section 127.12(c)(2). The submitter is encouraged to provide detail of remedial measures and mitigating factors by uploading a document in Block 5 by choosing “Voluntary Disclosure Narrative” for Document Type.
Empowered Official/Senior Officer Certification	Certification statement signed by an empowered official or senior officer. For submissions by non-registered parties (e.g., non-U.S. entity), the certification statement should be signed by an empowered official equivalent under delegation of authority from a senior officer. The executed certification statement is required for a full voluntary disclosure. This is required if the submission type is “Full Disclosure”.
Response to DTCC Inquiry	If the submission is in response to a DTCC inquiry, provide responses and relevant documents to the inquiry.
Audit Report	If relevant to the submission, provide the related audit report(s).
Compliance Program Manual, Policy, or Procedure	If appropriate, provide compliance program manuals, policies, procedures, or other compliance-related materials.
Technical Data	If the violation involves technical data, provide copies of the technical data.
Extension Request Letter	If the submission is requesting an extension to the 60-day deadline for submitting the full voluntary disclosure or an extension request to a DTCC inquiry, the submission must be accompanied by a written extension request as required by ITAR Section 127.12(c)(2) from an empowered official or senior officer.
Technology Control Plan	If relevant to the submission, provide related technology control plans.
Authorization Document	If relevant to the violations, corrective actions, or mitigating factors, provide licenses, agreements, general correspondences, end-user statements/certificates, import permits, exemption citations, or other authorization documents.
Shipping Document	If relevant to the violations, corrective actions, or mitigating factors, provide Electronic Export Information, Internal Transaction Number, air waybills, bills of lading, invoices, or other associated documents.
Training Document	If relevant to the violations, corrective actions, or mitigating factors, provide training records, materials, agendas, dates of attendance, the trainer’s name and credentials, and attendance sheets with names, titles, and signatures of attendees.
Notification Letter	If Submission Type is “Notification,” provide information concerning the notification.
Exhibit	If relevant to the violations, corrective actions, or mitigating factors, provide exhibits.
Other	If relevant to the violations, corrective actions, or mitigating factors, provide other documents that may substantiate a claim made in the disclosure. This may include timelines, matrices, written correspondence, emails, contracts, and/or resumes. Specify the type of document in the space provided.

BLOCK 6. SUBMISSION AUTHORIZATION

Check the box to confirm that the submitter is an authorized employee of the company cited in Block 1, or an authorized third party as indicated in Block 2 to submit on behalf of the company in Block 1. The submitter certifies to the accuracy and completeness of the submission, and has not knowingly omitted information. This is mandatory, except for submission type “Notification”.

the DS-7787 form is used to collect other correspondence that is not a voluntary disclosure (e.g., extension request, notification, other). Block 6 Submission Authorization applies to all submissions types collected under this form. Block 6 is mandatory for all submission types except for Notification.

The purpose of 22 CFR 127.12(e) certification is for voluntary disclosures only. For voluntary disclosures, submitters should submit a certification in accordance with 22 CFR 127.12(e). Under Block 5, relevant documents, the submitter should upload the certification under the document type, “Empowered Official/Senior Officer Certification.”

DS-7787 v3.13 Page 1 of 1

2019-07-01