Qualifying Advanced Energy Project Credit Allocation Program - Application

This format is provided for the convenience of the applicant; however, the applicant is not required to use this specific format. If another format is used, the signatory must include the same substantive information, a signature, date, and the certification statement provided below.

[Applicant Name]

[Applicant Website Address]

[Project Title]

[Application Control #]

TRANSPARENCY OF FOREIGN CONNECTIONS DISCLOSURE AND CERTIFICATION

For the Authorized Official of the Applicant

1. Do any non-U.S. citizens serve as members of your organization’s board of directors (or similar governing body), officers, executive personnel, general partners, regents, trustees, or senior management officials? _______

If yes, please disclose the following information.

First and Last Name	Title/Role (e.g., Member of Board of Directors, Officer, etc.)	Citizenship
☐ Check box if this table contains trade secrets or commercial or financial information that is privileged or confidential and exempt from public disclosure.

2. Is there a joint venture or subsidiary, of your business entity that is based in, funded by, or has a foreign affiliation with any foreign country of risk? ☐ Yes ☐ No If yes, please disclose the following information.

Entity Name	Address	Country	Relationship (i.e., joint venture, subsidiary)
☐ Check box if this table contains trade secrets or commercial or financial information that is privileged or confidential and exempt from public disclosure.

3. Is your company wholly or partially owned by foreign state-owned entity or an entity incorporated or otherwise formed in a foreign country of risk?

☐ Yes ☐ No If yes, please disclose the following information.

Name of Entity Incorporated or Otherwise Formed in a Foreign Country of Risk/Name of Foreign State-Owned Entity	Country	Percentage of Ownership
☐ Check box if this table contains trade secrets or commercial or financial information that is privileged or confidential and exempt from public disclosure.

4. Does your business entity have any investors that are investment funds (e.g., venture capital, private equity, or institutional investment)? ☐ Yes ☐ No If yes, proceed to question 4a and 4b. If no, proceed to question 5.

4a. Does the investing entity have a general partner or individual holding a leadership role who has a foreign affiliation with any foreign country of risk? ☐ Yes ☐ No

If yes, please populate the table below.

4b. Does the investing entity have agreements with your company providing substantive rights granting access to information, including but not limited to access to intellectual property, trade secrets, research and development (R&D), technology, business strategy, or financial matters? ☐ Yes ☐ No

If yes, please disclose the following information.

Name of Investor	Percentage of Investment	Type of Investment (e.g., equity, debt, or equity and debt)	Date of Investment	Entity Name with Agreement	Summary Agreement Rights
☐ Check box if this table contains trade secrets or commercial or financial information that is privileged or confidential and exempt from public disclosure.

5. During the previous 5-year period, did your business entity have any technology licensing or intellectual property sales (or any other transfer of intellectual property) to a foreign country of risk? ☐ Yes ☐ No If yes, please disclose the name and address of the institution that licensed or purchased the intellectual property.

Licensee or Intellectual Property Buyer Name	Foreign Country of Risk	Street Address	City	State	Zip	Country
☐ Check box if this table contains trade secrets or commercial or financial information that is privileged or confidential and exempt from public disclosure.

6. Does your business entity have any current or pending contractual or financial obligation or other agreement specific to a business arrangement, or joint venture-like arrangement with an enterprise owned by a foreign state-owned entity or a foreign entity of a country of risk? ☐ Yes ☐ No If yes, please disclose the following information.

Enterprise or Foreign Entity Name	Relationship Type (i.e., current or pending contractual arrangement, financial obligation, other agreement/business arrangement, joint venture-like arrangement)	Description of Relationship	Enterprise Owned by a Foreign State (Y/N)	Foreign State/Entity Country Name
☐ Check box if this table contains trade secrets or commercial or financial information that is privileged or confidential and exempt from public disclosure.

7. Does your business entity use any foreign suppliers from a country of risk? ☐ Yes ☐ No If yes, please disclose the name and address of the entity, the relationship of the foreign supplier to your business entity, and the supplier(s) place of incorporation.

Supplier Name	Description of Relationship (contractor, subsidiary, parent company, etc.)	Address of Supplier	Supplier(s) Place of Incorporation
☐ Check box if this table contains trade secrets or commercial or financial information that is privileged or confidential and exempt from public disclosure.

8. Are any members of your organization’s board of directors (or similar governing body), officers, executive personnel, general partners, regents, trustees, or senior management officials a party to or have any current or past involvement in the last ten years with any foreign government-sponsored talent recruitment program (FGTRP) of any foreign country of risk? ☐ Yes ☐ No If yes, please disclose the following information.

First and Last Name	Role (Owner, Officer, or Covered Individual)	Type of Involvement in the FGTRP	Current Country of Residence	Name of FGTRP	Dates of Involvement and Date Involvement Ended, if applicable

9. Provide a complete capitalization table for your company, including all equity interests (including LLC and partnership interests, as well as derivative securities). Include both the number of shares issued to each equity holder, as well as the percentage of that series and all equity on a fully diluted basis. Identify the principal place of incorporation (or organization) for each equity holder. If the equity holder is a natural-born U.S. person, identify the citizenship(s). If the company is a publicly traded company, provide the above information for shareholders with an interest greater than five percent.

10. Provide a summary table identifying all rounds of financing, the purchase dates, the investors for each round, and all the associated governance and information rights obtained by investors during each round of financing.

11. Add below an organization chart to illustrate the relationship between your company and the immediate parent, ultimate parent, and any intermediate parent, as well as any subsidiary or affiliates. Identify where each entity is incorporated.

I am providing this disclosure and certification on behalf of the above referenced applicant as part of my responsibilities as the applicant’s authorized official. I certify to the best of my knowledge and belief that the information contained in this document is true, complete, and accurate. I understand any false, fictitious, or fraudulent information, misrepresentations, half-truths, or omissions of material fact, may subject me to criminal, civil, or administrative penalties for fraud, false statements, false claims or otherwise. (18 U.S.C. §§ 1001 and 287, and 31 U.S.C. 3729-3733 and 3801-3812). I further understand and agree that: (1) the statements and representations made in this document are material to U.S. Government’s selection decision under the 48C program.
Authorized Official:	Title:
Signature:	Date:

Definitions

1. Foreign Government-Sponsored Talent Recruitment Program. An effort directly or indirectly organized, managed, or funded by a foreign government to recruit science and technology professionals or students (regardless of citizenship or national origin, and whether having a full-time or part-time position). Some foreign government-sponsored talent recruitment programs operate with the intent to import or otherwise acquire from abroad, sometimes through illicit means, proprietary technology or software, unpublished data and methods, and intellectual property to further the military modernization goals and/or economic goals of a foreign government. Many, but not all, programs aim to incentivize the targeted individual to physically relocate to the foreign state for the above purpose. Some programs allow for or encourage continued employment at U.S. research facilities or receipt of Federal research funds while concurrently working at and/or receiving compensation from a foreign institution, and some direct participants not to disclose their participation to U.S. entities. Compensation could take many forms including cash, research funding, complimentary foreign travel, honorific titles, career advancement opportunities, promised future compensation, or other types of remuneration or consideration, including in-kind compensation.

2. Foreign Country of Risk. DOE has designated the following countries as foreign countries of risk: Iran, North Korea, Russia, and China. This list is subject to change.

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