Form DHS FORM 10001 (10 DHS FORM 10001 (10 APPLICATION FOR TRANSFER OF SAFETY ACTDESIGNATION AND CE

OMB No. 1640-0001
Expires 10/31/06

DEPARTMENT OF HOMELAND SECURITY

APPLICATION FOR TRANSFER OF SAFETY ACT
DESIGNATION AND CERTIFICATION

SELLER INFORMATION
T1. Name:
T2. QATT Information
T2.1 QATT Name:
T2.2 QATT Application Identification Number:

TRANSFEREE INFORMATION
T3. Name:
T3.1 Transferee's place of incorporation:

DESCRIPTION OF TRANSFER
T4. Effective date of transfer:

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T5. Attach a description of the transfer agreement and supporting information as
necessary.
T6. Insurance. Please provide information regarding the Transferee's insurance
coverage for the relevant QATT and whether the Transferee's coverage satisfies
the terms of insurance of the SAFETY Act Designation issued to the Transferor.
T7. Please provide information regarding the described transfer's effect on the
QATTs safety or efficacy, or risk(s) associated with its deployment.

DHS FORM 10001 (10/06)

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DECLARATION FOR WRITTEN SUBMISSIONS
I declare, to the best of my knowledge and belief, that the information provided in response to the
questions set forth in this Application for SAFETY Act liability protections is true, factual, and correct,
and that I am an authorized agent of the Applicant.
Prepared By:

Title (if applicable):

Signature:

Date:

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/20

The signature of the Preparer must be notarized below:
State of:
Subscribed and sworn before me this

County of:

day of

Notary Public:
My Commission Expires on:

Privacy Act Notice: DHS will use the information on Form OMB 1640-0001 to determine eligibility for the requested
SAFETY Act protections. This information is to be regarded as “SAFETY Act Confidential” and protected from release
pursuant to §25.10 of the Regulations Implementing the SAFETY Act of 2002, 6 C.F.R., Part 25, 71 Fed. Reg. 33147,
33159 (June 6, 2006).
Burden Statement: Public reporting burden for this form is estimated at 6 hours per response, including the time for
reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and
checking the collection forms. This effort is necessary to obtain or retain a benefit, as required by Public Law 107-296,
Subtitle G of Title VIII of the Homeland Security Act of 2002. Written comments regarding this form should be
submitted to the Office of SAFETY Act Implementation, Department of Homeland Security, Science and Technology
Directorate. Comments should be addressed and mailed to Silvia Cabrera, Acting Director OSAI, Department of
Homeland Security/ Science and Technology Directorate, Washington, D.C. 20528, or sent via electronic mail to silvia.
cabrera@dhs.gov, or faxed to (703) 575-8416.

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