Form 11 Application for Approval of Commodity Eligibility

OMB No. 0412-0004 Expiration Date 10/31/2008

APPLICATION FOR APPROVAL OF COMMODITY ELIGIBILITY (FORM AID 11)

Transaction No. (Assigned by USAID)      

TRANSACTION IDENTIFICATION

1. USAID Letter of Commitment No.      

2. Payment Terms

U.S. Bank Letter of Credit

Name and Address of U.S. Bank (Advising Bank)

Other Payment Terms (If any)

No.      

Date      

     

     

3. Import License

4. Supplier’s Relationship to Authorized Source Country

No.      

Date      

Corporation or Partner- ship Organized under Source Country Laws

Individual: Citizen or Permanent Resident of Source Country

Controlled Foreign Corporation

Other

5. Supplier’s Name and Address      

6. Importer’s Name and Address      

7. Contract

8. Shipping Plans at Time of Application

Total Amount (Funded by USAID)      

Date      

a. Partial Shipment No Yes $     

b. Loading Port      

c. Destination Port      

d. Month(s) of Shipment      

COMMODITY IDENTIFICATION
9. Schedule B 10-Digit Code(s) (a)      		10. Commodity Description, Quantity, Size      				11. Unit and Unit Price, or Total FAS/FOB Vessel Price, or FCA Price (Named Port of Loading/Airport)      
(b)      		     				     
(c)      		     				     
(d)      		     				     
(e)      		     				     
12. Commodity Condition: New and Unused Used - Not Rebuilt or Reconditioned Rebuilt Reconditioned Other (Specify below)      
13. Source of Commodity				14. Components (Parts of the Commodity)
a. Authorized Area      	b. Shipped From      		c. Produced In      	a. From Other than 13.a Source Yes No	b. If 14.a is “Yes”, Name Country Imported From      		c. Cost Per Unit of 14.b Components      

AID 11 (03/08) Page 1

AID 11 (03/08)	OMB No. 0412-0004 Expiration Date: 10/31/2008
15. State the Producer Name and Address, if not the Supplier. Remarks and Additional Information, if any.      

16.	SUPPLIER’S CERTIFICATIONS

As a condition for securing a determination of commodity eligibility for funds made available by the United States under the Foreign Assistance Act of 1961, as amended, for payment in whole or in part in the transaction described and for the commodity identified on this form, the undersigned, acting on behalf of the supplier whose name appears in Block 5 above and authorized to bind the supplier, agrees with and certifies to USAID as follows: 1. The supplier has contracted with the importer named in Block 6 for the purchase of the commodity described on this form, and the supplier has either attached to this form a copy of such contract or has furnished in Block 2 information concerning a letter of credit confirmed or advised in its favor under a payment obligation assumed by the importer in the contract. 2. The supplier has filled in the applicable portions of this form and certifies to the correctness of the information shown herein. 3. The supplier agrees that the commodity will be shipped and invoiced in accordance with the information shown herein; that if any change in commodity identification takes place after USAID has approved this transaction, the supplier will resubmit this form to USAID for review and further approval for financing in light of the changed commodity; and that this Commodity Approval Application which the supplier proposes to use as a basis for securing payment from USAID funds, is in every respect the original or true copy of the original application approved by USAID. The supplier acknowledges that any commodity, other than a commodity described on this form by the supplier and approved by USAID below, is ineligible for USAID financing with respect to the purchase transaction for which this form must be submitted as a condition for payment. 4. The supplier certifies that it is an individual citizen or lawfully admitted permanent resident of a country included in the authorized

source code; a corporation or partnership organized under the laws of a country included in the authorized source code and with a place of business in such country; or a controlled foreign corporation (within the meaning of § 957 et seq. of the Internal Revenue Code) as attested by current information on file with the Internal Revenue Service of the United States (on IRS form 5471 or any substitute or successor forms) submitted by shareholders of the corporation, or a joint venture or unincorporated association consisting entirely of individuals, corporations or partnerships which fits any of the foregoing categories. If the supplier is a controlled foreign corporation without a regular place of business in the United States, the supplier appoints any shareholder or officer thereof agent for the supplier to receive service of process in the United States in connection with any dispute arising between the supplier and USAID and relating to the commodity sale financed by USAID. 5. The supplier has not, at the time of submission of this application, been debarred or suspended by USAID or placed on the “Lists of Parties Excluded from Federal Procurement or Non-procurement Programs,” published by the General Services Administration, or the Treasury Department’s “Consolidated List of Designated Nationals” and thereby rendered ineligible to receive USAID funds. To the best of its knowledge upon reasonable investigation, the supplier has not acquired, nor will it acquire, for resale under USAID financing the goods described on this form from any supplier included on the “Lists of Parties Excluded from Federal Procurement or Non-procurement Programs,” or included on the Treasury “Consolidated List of Designated Nationals” or from any affiliate of such a person. 6. The supplier acknowledges that this application, when approved, is not valid for shipments having a delivery date on or after the expiration date shown below.

      Type or Print Name and Title

Signature of Authorized Representative of Supplier

      Date

17.	USAID APPROVAL
By the signature and seal which appear below, USAID has given limited approval to the sale described on this form. This approval is limited strictly to a determination that the commodity which the supplier has described is of a description, condition, and source eligible for USAID financing. This approval and determination of commodity eligibility does not represent an approval of the purchase price and does not in any way preclude a USAID refund claim based				upon a detailed post-audit of the transaction in accordance with the provisions of USAID Regulation 1 (22 CFR 201). USAID expressly reserves such rights as it may have under that Regulation and under such other USAID forms as the supplier may be required to submit by the terms of financing documents and by the terms of Regulation 1.
E XPIRATION DATE      			APPROVED FOR USAID__________________________________________ Authorized Signature Date      
18.	CERTIFICATE FOR PARTIAL SHIPMENT

I hereby certify that the partial shipment for which payment is being requested from USAID funds is being made under the contract by the

original validated Form AID 11 of which this is a true copy.

           

_________________________________ ____________________________________________ ___________________

Typed or Printed Name and Title Signature of Authorized Representative of Supplier Date

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AID 11 (03/08)

OMB No. 0412-0004 Expiration Date 10/31/2008

GENERAL INSTRUCTIONS

Paperwork Reduction Act Notice. Information furnished will be used to verify compliance with legal requirements, as a basis for recourse in the event of noncompliance, and to monitor participation in USAID programs. It will be disclosed outside USAID only as provided by law. Submission of this information has been determined to be necessary to receive payment from USAID funds pursuant to 22 U.S.C. 2381. Public reporting burden for this collection of information is estimated to average thirty minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. The Agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: U.S. Agency for International Development Office of Acquisition and Assistance Policy Division (M/OAA/P) Washington, D.C. 20523-0001 and Office of Management and Budget Paperwork Reduction Project (0412-0004) Washington, D.C. 20503 Requirement for Payment. Section 201.11(k) of USAID Regulation 1 (22 CFR 201) declares that a commodity purchase transaction is eligible for USAID financing only if USAID provides a determination of the commodity eligibility on the Commodity Approval Application. Section 201.52(a) (8) of the Regulation states that to secure payment a supplier must submit the signed original of this form, countersigned by USAID. As appropriate, a reproduced copy of the validated form, certified as provided in the second paragraph following, is required with each subsequent claim for partial shipments made under the original validated Form AID 11. Alterations to Block 16 are not acceptable. Form submission and USAID approval. To secure USAID approval, a supplier must submit the signed and properly executed original and one copy of the form addressed to the USAID Commodity Office listed in the letter of credit or direct letter of commitment pursuant to which this approval of commodity eligibility is requested. USAID will indicate its approval in Block 17 of the form if the form is properly executed and if USAID has no objection to financing the described commodity. If USAID refuses approval, the Agency will return the form to the supplier with an explanation for refusal. In either case, an identification number will be assigned by USAID in the upper right-hand corner of the form. Any follow-up correspondence between the supplier and USAID should refer to this number. Partial Shipments. In the event a supplier expects to make more than one shipment

under a single contract, letter of credit, or collection document, it may either submit a separate Form AID 11 covering each shipment, or submit a single Form AID 11 covering the entire contract. In the latter case, the original USAID-approved form will be presented to the paying bank with the supplier’s first request for payment and a reproduced copy of the approved form, properly certified in Block 18, will be presented with each request for payment for subsequent partial shipments. See detailed instructions for Block 8. Duration of USAID Approval. USAID approval remains valid for six (6) months as evidenced by the expiration date entered by USAID in Block 17. If the letter of credit is valid for a longer period, upon request from the supplier and submission of a copy of the letter of credit, USAID will provide an approved expiration date corresponding to the expiration date of the letter of credit. If the USAID approval expires prior to delivery, the supplier must reapply for approval, making reference to the transaction number assigned by USAID. Timing of Submission. Under letter of credit financing the application should be submitted subsequent to receiving confirmation or advice of credit, but prior to shipment. The form may, however, be submitted prior to receipt of such credit provided that an original or true copy of the purchase contract accompanies the application. Under any other method of financing, the application will be submitted following receipt of instructions that the transaction is to be USAID-financed and must be accompanied by an original or true copy of the contract with the importer. The form should not be submitted prior to the time the supplier is able to furnish all required information in Blocks 12 through 15. Language. Every commodity description which appears on the form must be stated in English. If a supplier furnishes as an attachment to this form a contract in a language other than English, an English translation of the commodity description must also be furnished. Completeness. All numbered blocks MUST be fully and appropriately completed. If the application contains incomplete blocks, it will NOT be processed but will be returned for completion. Obtaining Forms. The form is available as a macro on USAID’s website at http:// www.usaid.gov/forms. Forms may be obtained in limited quantities from banks holding USAID letters of commitment, field offices of the Department of Commerce, the USAID office in the supplier’s country, or the Information and Records Division (M/AS/IRD), U.S. Agency for International Development, Washington, D.C. 20523-2701. A supplier may reproduce the form provided the reproduction is identical with the original copy in every respect, including size, and format. A supplier may overprint its name and address in Block 5.

INSTRUCTIONS RELATING TO SPECIFIC ITEMS

BLOCK 1: Enter the letter of commitment number. If not available, enter the loan or grant agreement number. USAID cannot act on an application unless one of these numbers is provided. BLOCK 2: Indicate the method of financing. If by letter of credit, enter the letter of credit number assigned by the U.S. bank, the date the bank issued, advised, or confirmed the letter of credit, and the name and address of the bank concerned. If the application is submitted prior to receipt of this information, enter the words “Firm contract” and attach a copy of the contract. If the transaction is not to be financed by letter of credit, enter the applicable payment terms (e.g., sight draft collection, open account) and attach a copy of the contract. BLOCK 3: The importer should provide the supplier with this

information. Generally the import license number appears on the letter of credit. If the information is not known or is not available at the time of submission of the application, enter “Unknown.” (In some cases it may be necessary for USAID to require this information before approving the application.) Enter “N/A” (not applicable) if the importer has not been required by its government to secure an import license. BLOCK 4: Check the appropriate box to indicate the supplier’s relationship to a country or area in the authorized source code. This information relates to certification 4 in Block 16. If “Other” is checked, furnish explanation of relationship in Block 15. BLOCK 5: Enter name and address. BLOCK 6: Enter importer’s name and address.

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AID 11 (03/08)			OMB No. 0412-0004 Expiration Date: 10/31/2008
BLOCK 7: Enter the purchase price funded by USAID under the contract. Enter contract date or date pro forma invoice was accepted. BLOCK 8: a. Check the appropriate box to indicate whether the supplier expects to make partial shipments. If “yes” and a separate application form will be submitted for each partial shipment, enter the value of the shipment to which this application relates. If only one application form will be submitted to cover all partial shipments, omit the dollar value. b. Enter the proposed loading port. If only the range of ports is known, enter the range of ports; e.g., North Atlantic, South Atlantic, Gulf, Pacific, Great Lakes. If expected that partial shipments will be made, but only one application form is to be submitted, entries under b and c will relate to the first shipment only. c. Enter the proposed destination port. d. Enter the month in which it is expected shipment will be made. In the case of partial shipments, indicate the estimated first and last months of shipments: e.g., April-September. BLOCKS 9 and 10: Enter the U.S. Department of Commerce Schedule B 10-digit code in Block 9 and describe the commodity in Block 10, giving size, quantity, and a clear word description of the commodity, including any special formula or other distinguishing characteristics, such as substandard quality (e.g., reject, imperfect, second) which will help to identify it. If the contract or letter of credit identifies the commodity by other than Schedule B code (e.g., importing country tariff classification), this identification should be furnished as part of the commodity description. If the commodity description varies significantly within the same Schedule B Code, separate entries must be furnished for each commodity. BLOCK 11: Enter the unit and unit price, or total, for the commodity on an FAS, FOB, or FCA basis for the loading port/airport specified in Block 8b. For other delivery terms, enter a constructive price FAS or FOB vessel or FCA port/airport; i.e., subtract from a CFR or CIF price estimated ocean/air freight and accessorial costs necessary to place the commodity in the custody of the ocean carrier or airline. If the supplier is unable to compute a unit price FAS or FOB vessel or FCA named airport, the unit price of the commodity may be shown on the basis of the inland price with estimated inland freight cost, if available, footnoted in an explanatory entry in Block 15. SPECIAL INSTRUCTIONS—MULTIPLE ITEMS: If the shipment (or contract) is made up of commodities bearing differing Schedule B codes, or if the commodity description varies significantly within the same Schedule B code, separate entries must be furnished for each code or description. When there are six or more items to be listed in Blocks 9 through 11, a signed and dated accepted contract, order, invoice, or other separate listing of the information may be attached to the original and copy of the Form AID 11, provided the full 10-digit Schedule B code, complete and accurate description of the commodity, and FAS or FOB vessel or FCA airport unit price are shown for each. If the information required by Blocks 12 through 14 is not common to all commodities listed, appropriate information related to each such commodity is also required to be shown either on the attachment or in the Blocks 12 through 14 and related to the appropriate line of the attachment. If an attachment is used in lieu of entry of the information on Form AID 11, complete Blocks 9 – 11 inclusive, and 12 – 14 inclusive (when applicable) by entering the words “See attachment.”		SPECIAL INSTRUCTIONS—BLOCKS 12 through 14: If more than one commodity is listed in Block 9, provide information required by Blocks 12 through 14 on separate lines in those Blocks, identified to the corresponding line on which the commodity is listed in Block 9. For example, information concerning a commodity listed on line (c) in Block 9 would be identified as line (c) in Blocks 12 through 14. When only one Form AID 11 is submitted, information in these blocks should be descriptive of the total contract. If a separate Form AID 11 is submitted for each shipment under the contract, the information in these blocks should cover only that single shipment. BLOCK 12: Enter check mark in the appropriate box to indicate the condition of the commodity. If the commodity is other than new and unused, describe the condition in the space below or in Block 15. For this purpose, any commodity declared surplus by any U.S. Government agency and any commodity which has been rebuilt or reconditioned or contains components which have been rebuilt or reconditioned are not considered as “unused.” BLOCK 13: See 22 CFR 228.03 for countries and areas included in geographic code numbers. a. Enter in Block 13a the authorized geographic source area stated in the letter of credit or USAID direct letter of commitment. b. Enter in Block 13b the country from which the commodity will be shipped to the importer. If the commodity will be shipped from a free port or bonded warehouse, indicate this fact in Block 16 and give location. c. Enter in Block 13c the country in which the commodity has been or will be mined, grown, or produced through manufacturing, processing or assembling. BLOCK 14: a. Enter “Yes” in Block 14a if the commodity includes components imported into the country of production from a country not included in the authorized geographic source area indicated in Block 13a. If such components are not included, enter “no.” b. If yes is entered in Block 14a, identify in Block 14b each country from which components were imported into the country of production. c. In Block 14c, enter the total cost, within each unit of the finished product, attributable to components imported from each country indicated in Block 14b. The supplier must thereafter be prepared to demonstrate the accuracy of the information contained in Block 14a, b and c upon the request of USAID. BLOCK 15: If the supplier is not the producer of the commodity listed in Block 9, state the producer’s name and address. This block may also be used to furnish explanation or additional information in connection with any entries on the form. Identify block (and line, as appropriate) to which entry relates. BLOCK 16: The supplier, or its authorized representative, must manually sign this certification, showing name, title and date signed. BLOCK 17: For USAID use. Note that USAID approval is not valid for deliveries on and after the expiration date shown in this Block. BLOCK 18: If reproduced copies of this original form are presented with the supplier’s request for payment (see fifth paragraph of General Instructions), the supplier or its authorized representative must manually sign this certification in Block 18 of the reproduced form, showing name, title and the date signed.

DO NOT INCLUDE THE INSTRUCTIONS ON PAGE 3 AND 4

WITH THE SUBMISSION OF THE COMPLETED FORM.

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