Form CFIUS Declaration CFIUS Declaration Declaration Submission Form for Covered Control Transact

U.S. DEPARTMENT OF THE TREASURY

Declaration Submission Form for Covered Control Transactions and Covered Investments Under 31 C.F.R. Part 800

IMPORTANT: All fields on this form are required unless otherwise explicitly noted.

1. List the foreign person(s) and U.S. business(es) that are parties to, or, in applicable cases, the subject of the transaction, as well as the name, telephone number, and email address of the primary point of contact for each party:

U.S. Business Foreign Person(s)

Name: Name:

Point of Contact: Point of Contact:

Telephone: Telephone:

Primary email: Primary email:

Secondary contact email (optional): Secondary contact email (optional):

2. Are all parties to this transaction submitting this declaration jointly? ⃝ Yes ⃝ No

3. Briefly describe the rationale for and nature of the transaction, including its structure (e.g., effectuated via a share purchase, merger, asset purchase):

4. Provide the percentage of voting interest acquired and the resulting aggregate voting interest held by the foreign person and its affiliates:

5. Provide the percentage of economic interest acquired and the resulting aggregate economic interest held by the foreign person and its affiliates:

6. Does/do the U.S. business(es) have multiple classes of ownership? ⃝ Yes ⃝ No

7. Total transaction value in U.S. dollars:

8. Actual or expected completion date of the transaction:

9. Provide a list of all sources of financing for the transaction:

10. Attach here the definitive documentation of the transaction, or, if none exists, the document(s) establishing the material terms of the transaction.

11. Do the parties to the transaction stipulate that the transaction is:

a. A covered transaction ⃝ Yes ⃝ No

b. A foreign government-controlled transaction ⃝ Yes ⃝ No

12. If applicable, describe the basis for the stipulation(s) above:

13. Will the foreign person acquire any of the following with respect to the U.S. business:

a. Access to any material nonpublic technical information in the possession of the U.S. business:

⃝ Yes ⃝ No

b. Membership, observer rights, or nomination rights, as set forth in 31 C.F.R. 800.211(b)(2):

⃝ Yes ⃝ No

c. Any involvement, other than through voting shares, in substantive decisionmaking of the U.S. business regarding critical infrastructure, critical technologies, or sensitive personal data as set forth in 31 C.F.R. 800.211(b)(3):

⃝ Yes ⃝ No

d. Any rights that could result in the foreign person acquiring control of the U.S. business?

⃝ Yes ⃝ No

For any affirmative response to 13.a – d, provide a brief explanation of such access, rights, or involvement as required by 31 C.F.R. 800.404(c)(4).

14. Provide the following regarding the U.S. business(es) involved in the transaction:

a. Website address:

b. Principal place of business:

c. Place of incorporation or organization:

15. List the addresses or geographic coordinates (at least to the fourth decimal) of all locations of the U.S. business, including the U.S. business(es)’ headquarters, facilities, and operating locations, (if necessary, attach a list here):

16. Summarize the business activities, as, for example, set forth in annual reports, of the U.S. business and any entity of which the U.S. business is a parent, and the product or service categories of each, including, as applicable, the relevant NAICS Code(s), CAGE Code(s), and DUNS identification number(s) for the U.S. business:

17. Does the transaction involve a U.S. business that:

a. Produces, designs, tests, manufactures, fabricates or develops a critical technology, as defined at 31 C.F.R. 800.215? (If yes, please respond to the questions in Annex A.) ⃝ Yes ⃝ No

b. Performs any of the functions as set forth in Column 2 of Appendix A to part 800 with respect to covered investment critical infrastructure, as defined at 31 C.F.R. 800.214? (If yes, please respond to the questions in Annex B.) ⃝ Yes ⃝ No

c. Maintains or collects sensitive personal data, as defined at 31 C.F.R. 800.241, of U.S. citizens? (If yes, please respond to the questions in Annex C.) ⃝ Yes ⃝ No

18. If the U.S. business has any contracts or subcontracts currently in effect or that were in effect with any U.S. government agency or component in the past three years, or in the past 10 years if the contract included access to personally identifiable information of U.S. Government personnel, attach an annex listing such contracts, including the information required at 31 C.F.R. 800.404(c)(10) here.

19. Does the U.S. business have any contracts or subcontracts currently in effect or that were in effect within the past five years involving information, technology, or data classified under Executive Order 12958? ⃝ Yes ⃝ No

20. Has the U.S. business received any grant or other funding or participated in or collaborated on a program or product as set forth in 31 C.F.R. 801.404(c)(12)? ⃝ Yes ⃝ No

21. Has the U.S. business participated in a Defense Production Act Title III Program within the past seven years? ⃝ Yes ⃝ No

22. If the U.S. business received or placed any priority rated contracts or orders under the Defense Priorities and Allocations Systems (DPAS) regulation within the past three years, provide the priority of such contracts or orders (DX or DO):

23. Name of the ultimate parent of the foreign person:

24. Provide the principal place of business and address of the foreign person, ultimate parent, and ultimate owner of such parent:

25. Attach here a complete pre- and post-transaction organizational chart including, without limitation, information that identifies the name, principal place of business and place of incorporation or other legal organization (for entities), nationality (for individuals), and ownership percentage (expressed in terms of both voting and economic interest, if different) for each of the following:

a. The immediate parent, the ultimate parent, and each intermediate parent, if any, of each foreign person that is a party to the transaction;

b. Where the ultimate parent is a private company, the ultimate owner(s) of such parent;

c. Where the ultimate parent is a public company, any shareholder with an interest of greater than five percent in such parent; and

d. The U.S. business that is the subject of the transaction, both before and after completion of the transaction.

26. Information regarding all foreign ownership in a foreign person’s ownership structure, including nationality and percentage of ownership, as well as any rights that a foreign government holds, directly or indirectly, with respect to the foreign person:

27. Summarize the business activities as, for example, set forth in annual reports, of the foreign person that is party to the transaction and any of its parents, as applicable:

28. If any party to the transaction has been party to another transaction(s) previously notified or submitted to the Committee, provide the case number(s) assigned by the Committee regarding such transaction(s):

29. Provide a brief statement as to whether the U.S. business, the foreign person, or any parent or subsidiary of the foreign person has been convicted of a crime in any jurisdiction within the past ten years, including the relevant jurisdiction and criminal case law number or legal citation.

30. Attach here a certification from each party submitting the declaration that the information contained in the declaration is consistent with 31 C.F.R. 800.204.

ANNEX A – CRITICAL TECHNOLOGIES

1. Identify all critical technologies the U.S. business produces, designs, tests, manufactures, fabricates, or develops. Indicate whether the critical technology is: listed on the United States Munition List (USML) or the Commerce Control List (CCL); covered by 10 C.F.R. part 810, 10 C.F.R. part 110, 7 C.F.R. part 331, 9 C.F.R. part 121, or 42 C.F.R. part 73; or controlled pursuant to section 1758 of the Export Control Reform Act of 2018. Include information on the applicable category (e.g., classification number).

   Critical Technology	Role of the U.S. business with respect to such technology (i.e., does it produce, design, test, manufacture, fabricate and/or develop)	Applicable export control classification (i.e., USML or CCL Category) or other basis for control

2. Describe any critical technologies identified in question 1, including a brief description of the U.S. business’s role with respect to the critical technologies and the uses of such technologies.

ANNEX B – CRITICAL INFRASTRUCTURE

1. Identify which functions set forth in Column 2 of appendix A to 31 C.F.R. part 800 the U.S. business performs with respect to covered investment critical infrastructure:

Covered investment critical infrastructure	Function related to covered investment critical infrastructure (i.e., does it own, operate, manufacture, supply, and/or service)

2. Specifically describe the applicable covered investment critical infrastructure and how the U.S. business performs each function identified in question 1 with respect to the applicable covered investment critical infrastructure.

ANNEX C – Sensitive Personal Data

1. Identify the category or categories of sensitive personal data, as specified at 31 C.F.R. 800.241(a)(1)(ii), that is identifiable and that the U.S. business has maintained or collected, maintains or collects, or intends to maintain or collect:

Sensitive Personal Data Category

2. Provide the approximate number of total unique individuals from whom sensitive personal data, as defined at 31 C.F.R. 800.241, is currently maintained and has been maintained or collected over the last 12 months:

3. Describe whether the U.S. business targets or tailors products or services to U.S. Government personnel or contractors from whom it maintains or collects sensitive personal data: