Form DS4100 Iran Democracy Program Grants

OMB APPROVAL NO. 1405-xxxx
EXPIRATION DATE: xx-xx-xxxx
ESTIMATED BURDEN: 1HOUR

U.S. Department of State

IRAN DEMOCRACY PROGRAM GRANTS
Bureau of Near Eastern Affairs (NEA)
Name of Organization

Address of Organization

Grant Title

Title of The Position

Name (Last, First, MI.)

Date of Birth
(mm-dd-yyyy)

Place of Birth

Nationality

President
Treasurer
Board of Directors
Board of Directors
Board of Directors
Board of Directors
Program Director
Program Assistant(s)
Program Assistant(s)
Contractors/Sub Grantees
Contractors/Sub Grantees
Contractors/Sub Grantees
Contractors/Sub Grantees

PRIVACY ACT STATEMENT
The information collected is solicited to assist the U.S. Department of State to effectuate the goals of sections 481(b), 531(a), 571, 582, and
635(b) of the Foreign Assistance Act of 1961 (as amended); 18 U.S.C. § 2339A and 2339B; Executive Order 13224; and Homeland Security
Presidential Directive 6. The information collected will be used to ensure that the Department of State complies with relevant laws and
regulations designed to prevent U.S. persons and funds from supporting terrorists or terrorist activity. The information collected may be
released to federal, state, or local agencies in the United States, or foreign agencies, for the purpose of considering the relevant grant or
sub-grant application(s), or for law enforcement, counter-terrorism, or homeland security purposes; to the United States Congress and
U.S.courts within their sphere of jurisdiction; and to other federal agencies for certain personnel and records management matters. Failure to
provide the requested information may result in the denial of your application for a grant or contract.

PAPERWORK REDUCTION ACT STATEMENT
Public reporting burden for this collection of information is estimated to average one hour per response, including time required for searching
existing data sources, gathering the necessary documentation, providing the information and/or documents required, and reviewing the final
collection. You do not have to supply this information unless this collection displays a current valid OMB control number. If you have
comments on the accuracy of this burden estimate and/or recommendations for reducing it, please send them to: U.S. Department of State,
A/ISS/DIR, 1800 G St. NW, Washington, DC 20520

DS-4100
12-2006