Business Entity Certification 48C

ATTACHMENT A

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

DEPARTMENT OF ENERGY

TRANSPARENCY OF FOREIGN INFLUENCE DISCLOSURE AND CERTIFICATION

For the Authorized Official of the Entity

Entity Name: [INSERT]

Application Number: [INSERT]

1. Board Membership of Entity

Provide a current and complete list of all directors (and board observers), including full name, citizenship and shareholder affiliation (if applicable), date of appointment, duration of term. 

2. Ownership Structure of Entity

Provide a complete and current capitalization table of the Entity, including all equity interests (including LLC and partnership interests, as well as derivative securities). For each equity holder, identify the place of incorporation and principal place of business (for entities) or the citizenship and current country of residence (for natural persons). If the Entity is a publicly traded corporation, provide the place of incorporation and principal place of business (for entities) or the citizenship and current country of residence (for natural persons) for equity holders with an interest greater than five percent. For each equity holder not incorporated or having its principal place of business in the United States (for entities), identify whether the equity holder is a foreign government-owned or controlled entity (if known, after due inquiry).

3. Organization Chart

Attach a complete and current organization chart depicting the relationship between the Entity and its immediate parent, ultimate parent, and any intermediate parent, as well as any subsidiaries or affiliates (including joint ventures). For each legal entity identified on the chart include the place of incorporation and principal place of business; for any individual identified on the chart include the nationality. For any legal entity or individual identified on the chart include ownership percentage (expressed in terms of both voting and economic interest, if different) between and among the various entities.

4. Licensing

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

   2. During the previous 5-year period, did the Entity license any technology or intellectual property from a foreign country of risk? ☐ Yes ☐ No. If yes, please disclose the name and address of the entity or individual in the foreign country of risk that licensed the intellectual property to the Entity.

Licensee/Licensor or Buyer/Seller Name	Description of Intellectual Property		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.

5. Foreign Government-sponsored Talent Recruitment Programs

Is any beneficial owner, officer, director, or board observer of the Entity a party to or have any current or past involvement in the last seven years with any foreign government-sponsored talent recruitment program (FGTRP) of any foreign country of risk? ☐ Yes ☐ No If yes, please disclose the name of each owner, officer, director, or board observer and the FGTRP.

First and Last Name	Role (Owner, Officer, Director, or Board Observer)	Type of Involvement in the FGTRP, including receiving financial or in-kind support	Current Country of Residence	Name of FGTRP	Dates of involvement

I am providing this disclosure and certification on behalf of the above referenced entity as part of my responsibilities as the entity’s authorized official for the above referenced application. 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. 3729-3730 and 3801-3812). I further understand and agree that the statements and representations made in this document are material to the government’s selection decision.
Authorized Official:	Title:
Signature:	Date:

Definitions

1. Foreign Government-Sponsored Talent Recruitment Program. An effort formal or informal, directly or indirectly organized, managed, or funded by a foreign government (including sub-national governments at the provincial, regional, or city level) 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, academic or professional recognition, 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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