Form DSP-6 Application for Amendment to a DSP-5 License

OMB APPROVAL NO. 1405-0092
EXPIRATION DATE: 05-31-2018
*ESTIMATED BURDEN: 30 MINUTES

Electronic Form Version Number: 9.3

* PAPERWORK REDUCTION ACT STATEMENT: Public reporting burden for this collection of information is estimated to average 30 minutes per response, including time
required for searching existing data sources, gathering the necessary data, providing the information required, and reviewing the final collection. Send comments on the
accuracy of this estimate of the burden and recommendations for reducing it to: Department of State (A/ISS/DIR) Washington, D.C. 20520.

U.S. DEPARTMENT OF STATE
APPLICATION FOR AMENDMENT TO A DSP-5 LICENSE
*Transaction Number:

Please note that an Asterisk (*) next to a field or block in a document designates a mandatory field or block.

No classified information can be included in this application. Classified information must be sent
separately to PM/DDTC in accordance with the Defense Security Service guidelines.
Classified information is being sent under separate cover

To open a document, click on a document to highlight it and select the "Open Document" button. The document that
you selected will open.
Required Documents
DSP-6
Copy of DoS License with PM/DDTC Proviso(s)

Optional Documents
22 CFR § 126.13 Certification Letter
22 CFR § 127.11 Exception to Policy Letter
DTCC Acknowledgement Letter
Other Amplifying Data
Other DSP-6 Authorizations
Purchase order submitted with original license

DSP-6

Included Documents

DSP-6, Page 1
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Amendment Control No.
Signature

The Indicated License is
Amended Effective on:

The License identified in Block 4 below is amended as requested on the date indicated
at the right of this form.

UNITED STATES OF AMERICA

DEPARTMENT OF STATE

APPLICATION FOR AMENDMENT TO A DSP-5 LICENSE
*1. Date Prepared

*2. DDTC Registration Code

02/15/2018

*4. Amendment to License #

3. Applicant

I certify that the stated license has an unshipped balance and has not expired.

Subsidiary

*5. Amendment in Accordance with

*Name

22 CFR 123.25

22 CFR 122.4

6. Compliance Case Number
*Attention

a. Provide Compliance Case Number

*Address
b. Provide date of DTCC Acknowledgement Letter (mm/dd/yyyy)

*City
*State

*ZIP Code
Ext.

*Telephone #

7. Applicant Contact for Additional Information

Item # 1:
Name
Telephone #

Ext

Add

*8. Summary of Amendment(s) to DSP-5

9. Change in DDTC Registration Code (DSP-5 Block 2)
a. State specific reason for the change:

b. DDTC Registration Code as stated on DSP-5 license:

c. New DDTC Registration Code:

10. Change in Applicant/Subsidiary (DSP-5 Block 5)

Item # 1:
a. Type of Modification:

b. State specific reason for the change:

c. Applicant/Subsidiary as stated on original DSP-5 license:

d. Modified Applicant/Subsidiary:

Name

Name

Attention

Attention

Address

Address

City

City

State

ZIP Code
Add

State

ZIP Code

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11. Change in Commodity Description (DSP-5 Block 10)

Item # 1:
a. Type of Modification:

Change part number

Correct typographical error

b. State specific reason for the change:

c. Change From - Commodity description to include the part number
as stated on original DSP-5 License:

d. Corrected Commodity description to include the part number:

Line Item #

Line Item #

Description

Description

Add

12. Change in Quantity (DSP-5 Block 9) and/or $ Value (DSP-5 Block 12)

Item # 1:
Correct Quantity

a. Type of Modification:

Correct Value

b. State specific reason for the change:

c. Change From - Quantity and/or $ Value as stated on original DSP-5 license:

Item #

Quantity

$ Value

Unit Price

d. Change to - Quantity and/or $ Value as it should appear:

Item #
Line Item Total

Unit Type

Quantity

Unit Type

Add

13. Change in DSP-5 License Total (DSP-5 Block 13)
a. Total $ value as stated on original DSP-5 license in Block 13:
b. Revised total $ value

14. Change in Foreign End-User (DSP-5 Block 14)

Item # 1:
a

Correct typographical error

b. Foreign End-User as stated on original DSP-5 license:

c. New Foreign End-User:

Name

Name

Address

Address

City

City
Add

$ Value

Unit Price

Line Item Total

DSP-6, Page 3

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15. Change in Manufacturer of Commodity (DSP-5 Block 15)
Item # 1:
a. Type of Modification:

b. State specific reason for the change:

c. Manufacturer of Commodity as stated on original DSP-5 license:

d. New/Modified Manufacturer of Commodity:

Name

Name

Address

Address

City

City

State

ZIP Code

State

Country

ZIP Code

Country

Add

16. Change in Source of Commodity (DSP-5 Block 17)
Item # 1:
a. Type of Modification:

b. State specific reason for the change:

c. Source of Commodity as stated on original DSP-5 license:

d. New/Modified Source of Commodity:

Name

Name

Address

Address

City

City
State

ZIP Code

State
Country

ZIP Code

Country

Add

17. Change in Foreign Consignee (DSP-5 Block 16)
Item # 1:
a. Type of Modification:

Change in name of original foreign consignee

b. State specific reason for the change:

Name Change

Change in address and/or city of original foreign consignee

Location Change

c. For any change where the license is in furtherance of an agreement, the applicant has completed the amendment to the agreement required by 22 CFR
124 to reflect this change:
Yes

No

Not Applicable

d. Foreign Consignee as stated on original DSP-5 license:

e. Modified Foreign Consignee:

Name

Name

Address

Address

City

City

Country
Add

Country

DSP-6, Page 4

18. Change in U.S. Seller (DSP-5 Block 19)
Item # 1:
a. Type of Modification:

Change in name of original U.S. seller
Change in address, city, state and/or ZIP code of original U.S. seller

b. State specific reason for the change:

c. U.S. Seller as stated on original DSP-5 license:

d. Modified U.S. Seller:

Name

Name

Address

Address

City

City

State

ZIP Code

State

ZIP Code

Add

19. Change in Foreign Intermediate Consignee (DSP-5 Block 18)
Item # 1:
a. Type of Modification:

b. State specific reason for the change:

c. Foreign Intermediate Consignee as stated on original DSP-5:

d. New Foreign Intermediate Consignee:

Name

Name

Address

Address

City

City

Country

Country

Add

20. Change in U.S. Consignor/Freight Forwarder (DSP-5 Block 21)
Item # 1:
a. Type of Modification:

b. State specific reason for the change:

c. U.S. Consignor/Freight Forwarder as stated on original
DSP-5 license:

d. New/Modified U.S. Consignor/ Freight Forwarder:

Name

Name

Address

Address

City

City

State

ZIP Code
Add

State

ZIP Code

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DSP-6, Page 5

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21. Additional Details of Transaction

* This application is related to a disclosure filed with Defense Trade Controls Compliance

No

Yes

Enter Compliance Disclosure Number:

*USML Category

Category

*22. Applicant's Statement
,

I,

an empowered official (22 CFR 120.25) or an official of a foreign government entity in the U.S., hereby apply for approval of the above amendment(s);
warrant the truth of all statements made herein; and acknowledge, understand and will comply with the provisions of 22 CFR 120-130, and any conditions
and limitations imposed.
I am authorized by the applicant to certify the following in compliance with 22 CFR 126.13:
(1) Neither the applicant, its chief executive officer, president, vice presidents, other senior officers or officials (e.g., comptroller, treasurer, general counsel)
nor any member of its board of directors is:
(a) the subject of an indictment for or has been convicted of violating any of the U.S. criminal statutes enumerated in 22 CFR 120.27 since the effective
date of the Arms Export Control Act, Public Law 94-329, 90 Stat. 729 (June 30, 1976); or
(b) ineligible to contract with, or to receive a license or other approval to import defense articles or defense services from, or to receive an export license
or other approval from any agency of the U.S. Government;
(2) To the best of the applicant's knowledge, no party to the export as defined in 22 CFR 126.7(e) has been convicted of violating any of the U.S. criminal
statutes enumerated in 22 CFR 120.27 since the effective date of the Arms Export Control Act, Public Law 94-329, 90 Stat. 729 (June 30, 1976),
or is ineligible to contract with, or to receive a license or other approval to import defense articles or defense services from, or to receive an export
license or other approval from any agency of the U.S. Government.

*22 CFR 126.13 Certification
a. I am authorized by the applicant to certify that the applicant and all of the parties to the transaction can meet in full the conditions of
22 CFR 126.13 as listed above.
b. I am authorized by the applicant to certify to 22 CFR 126.13. The applicant or one of the parties of the transaction cannot meet one or
more of the conditions of 22 CFR 126.13 as listed above. A request for an exception to policy, as described in 22 CFR 127.11 of the
ITAR, is attached.
c. I am authorized by the applicant to certify to 22 CFR 126.13. The applicant or one of the parties of the transaction cannot meet one or
more of the conditions of 22 CFR 126.13 as listed above. However that party has met the conditions imposed by the Directorate of
Defense Trade Controls in order to resume standard submission of applications, not requiring an exception to policy as described in
22 CFR 127.11 of the ITAR.
d. I am not authorized by the applicant to certify the conditions of 22 CFR 126.13. The applicant and all the parties to the transaction
can meet in full the conditions of 22 CFR 126.13 as listed above. Please see the attached letter from an official that is authorized
by the applicant to certify to the conditions of 22 CFR 126.13.
e. I am not authorized by the applicant to certify the conditions of 22 CFR 126.13. The applicant or one of the parties of the transaction
cannot meet one or more of the conditions of 22 CFR 126.13 as listed above. A request for an exception to policy, as described in
22 CFR 127.11 of the ITAR, and a letter from an official that is authorized by the applicant to certify to the conditions of
22 CFR 126.13 are attached.
f. I am not authorized by the applicant to certify to 22 CFR 126.13. The applicant or one of the parties of the transaction cannot meet one or
more of the conditions of 22 CFR 126.13 as listed above. However that party has met the conditions imposed by the Directorate of Defense
Trade Controls in order to resume standard submission of applications, not requiring an exception to policy as described in 22 CFR 127.11
of the ITAR. Please see the attached letter from an official that is authorized by the applicant to certify to the conditions of 22 CFR 126.13.

Signature

Signature

23. Response to be sent to: (Enter name, address and phone number:)
[Block is inactive on electronic form]
Name

ZIP Code

Attention

Ext.

Address
City
State
Telephone #

DSP-6, Page 6

CONDITIONS OF ISSUANCE
1. When approved, all of the original conditions and limitations except as modified by the Directorate of Defense Trade Controls remain applicable.
2. This amendment, when approved, becomes a part of the license identified in Block 4 on Page 1 of this form. When returned to the applicant, it
must be attached to the original license prior to further use of the license or must be provided to U.S. Customs and Border Protection for filing
with the original license.

DISPOSITION OF AMENDMENT
The final disposition of this amendment shall be in accordance with 22 CFR 123.22(c) and be accomplished with the final disposition of the
license identified in Block 4 on Page 1.

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Attachments pertaining to 22 CFR § 127.11 Exception to Policy Letter

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