DHS10002 - Notice of Modification

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

DEPARTMENT OF HOMELAND SECURITY

NOTICE OF MODIFICATION OF QUALIFIED ANTITERRORISM TECHNOLOGY

M1. Seller Name:
M2. Qualified Anti-Terrorism Technology (QATT) information
M2.1 QATT Name:
M2.1 QATT Application ID Number:
M3. Description of Modification: Attach a description of the modification the Seller has
made or is intending to make to the QATT. The discussion should endeavor to frame the
"before" and "after" attributes of the modifications to the QATT. Please also address
why the Seller is making or intends to make such modifications.
M4. Provide information regarding the described modification's effect on the QATTs safety
or efficacy, or risk(s) associated with its deployment.

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:

/

/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:

DHS Form 10002 (10/06)

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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.

DHS Form 10002 (10/06)

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