Form DS-6004 Request to Change End User, End Use and/or Destination o

Electronic Form Version Number: 0.19

OMB APPROVAL NO. ????
EXPIRATION DATE: ????
*ESTIMATED BURDEN: 1 Hour

* PAPERWORK REDUCTION ACT STATEMENT: Public reporting burden for this collection of information is estimated to average 1 hour per response, including
time required for searching existing data sources, gathering the necessary data, providing the information required, and reviewing the final collection. Send
comments on the accuracy of this estimate of the burden and recommendations for reducing it to: Department of State (A/RPS/DIR) Washington, D.C. 20520.

U.S. DEPARTMENT OF STATE
DIRECTORATE OF DEFENSE TRADE CONTROLS
REQUEST TO CHANGE END USER, END USE AND/OR DESTINATION OF HARDWARE

*Transaction Number:

Please note that an Asterisk (*) next to a field or block in a document designates a mandatory field or block.

No classified information can be included in this request. Classified information must be sent separately to DDTC
in accordance with the Defense Security Service guidelines.
Classified information is being sent under separate cover

To open a document, click on a document to highlight it and select the "Open Document" button. The document that you selected
will open.
Required Documents
DS-6004
Certification from Foreign Owner of Original Type of Acquisition

Included Documents

Open Document

Optional Documents
DSP-83
Purchase Order
Letter of Intent
Letter of Authorization from Foreign Owner
Technical Drawings, Schematics or Blueprints
Product Brochures
Other Amplifying Documents
Firearms and Ammunitions Import Permit
Firearms and Ammunitions Letter of Explanation
Certification Letter of Transaction from Non DDTC Registered Person
126.13 Eligibility Letter
Transaction Exception Request
Part 130 Report(Section 130.10)
Open Document

DS-6004
MM-YYYY Revised

Open Document

DS-6004, Page

1 of

3

DATE RECEIVED: 05/12/2005
CASE NO.

UNITED STATES OF AMERICA

DEPARTMENT OF STATE

REQUEST TO CHANGE END USER, END USE AND/OR DESTINATION OF HARDWARE
*1. Date Prepared 05/12/2005

*2. Type of Transfer (select one)

3. DDTC Applicant/Registrant Code

*4. Change in hardware's (select all that apply)

*Applicant is:

End Use

End User

5. Applicant Name, Address, ZIP Code and Tel. No.

Permanent

Temporary

Destination

6. Name and address of current foreign owner

I'm the original exporter of defense article(s)

Same as Block 5

A U.S. person submitting on behalf of foreign owner
A Foreign Embassy submitting on behalf of foreign owner

*Name

Current foreign owner
*Attention

Subsidiary
*Name

*Address
*City

*Attention

Country

*Country
*Address

Ext

*Telephone #

7. Name and telephone number of applicant contact(s)

*City

State

State

Name

ZIP Code

Telephone #

Country

*Country
*Telephone #

Add More Contacts

Ext

8. Country(s) of export

Country

View
Full
List

<==

Ext

9. Names, agency and telephone numbers of U.S. Government
personnel (not DDTC) familiar with the request
Name

Agency

Agency

Please Specify

10. USML Category Number
*USML Category

*Subcategory

USML Category
Line *11. Quantity
Item
#
1

Subcategory

Ext

Telephone #

Commodity Code

Add More Government Contacts

Commodity Code

*12. Commodity

13. $ Value
Unit Price

* Line Item Total

Unit Type
Calculate

*14. Is the Defense Article Significant Military Equipment (SME)?
*15. Is DSP-83 Required?

Yes

No

Yes

No

If SME and DSP-83 is not required, state why DSP-83 is not required
View Full
Explanation

*16. Is the Defense Article on the Missile Technology Control Regime (MTCR) Annex?
Add More Items

Yes

*17. Total Value (Sum of All Pages) $ $0.00

*18. The U.S. origin defense article(s) was previously authorized for export from the U.S. (Check at least one)
a.

by license no(s):

b.

by agreement (technical assistance or manufacturing agreement) no(s):

c.

by ITAR Exemption

d.

unknown or other:

No

Enter LIcense No(s)

Enter Exemption Citation
Enter Reason/Explanation

Enter Agreement No(s)

DS-6004, Page

2 of

Case No.
*19. Identify highest Government Security Classification of commodity to be transferred
a. The highest level of U.S. Government Security Classification is

(NOTE: Do not include classified information)

Classification

b. Is the commodity classified by the government of the current foreign owner?

Yes

No

If yes, provide the highest level of Foreign Government Security Classification
*20. Description of end use

*21. Name and address of foreign end user

Same as Block 6

Same as Block 5
Name

Address

City
Country

Country

View full Description

Add More Foreign End Users

*22. Name, address and role of foreign consignor (includes foreign
freight forwarder)

None

*23. Name, address and role of foreign consignee

None
Name

Name

Address
Address
City
City
Country

Country

Country

Country

Role

Role

Add More Foreign Consignees
Add More Foreign Consignors

24. Additional Details of Transaction

*25. Name and address of foreign intermediate consignee
None

Name

Address

City
Country
View full Description

Add More Foreign Intermediate Consignees

*28. Response to be sent to (Enter name, address and tel. no.)

[Block is inactive on electronic form.]
Name
Attention
Address
City
Country
Telephone #

Country

Country
Ext

3

DS-6004, Page

3 of

3

Case No.

26. U.S./Foreign Embassy Applicant Statement
, (Select one)

I,

am a citizen of the U.S., or have been lawfully admitted to the U.S. for permanent residence (and maintains such residence) under the Immigration and
Nationality Act, as amended, (8 U.S.C. 1101(a) (20), 66 Stat. 163); and an empowered official (ITAR 120.25) or an official of a foreign government
entity in the U.S. hereby apply for approval to complete the transaction above; warrant the truth of all statements made herein; and acknowledge,
understand and will comply with the provisions of Title 22 CFR 120-130, and any conditions and limitations imposed.
a U.S. person submitting on behalf of a foreign owner hereby apply for approval to complete the transaction above; warrant the truth of all statements
made herein; and acknowledge, understand and will comply with the provisions of Title 22 CFR 120-130, and any conditions and limitations imposed. I
have attached a letter certifying this transaction and an authorization/request from the foreign owner.
I am authorized by the applicant to certify the following in compliance with 22 CFR 126.13:
(1) Neither the applicant, its chief executive officer, president, vice presidents, other senior officers or officials (e.g., comptroller, treasurer, general
counsel) nor any member of its board of directors is:
(a) the subject of an indictment for or has been convicted of violating any of the U.S. criminal statutes enumerated in 22 CFR120.27 since the
effective date of the Arms Export Control Act, Public Law 94-329, 90 Stat. 729 (June 30, 1976); or
(b) ineligible to contract with, or to receive a license or other approval to import defense articles or defense services from, or to receive an export
license or other approval from any agency of the U.S. Government;
(2) To the best of the applicant's knowledge, no party to the export as defined in Section 126.7 (e) has been convicted of violating any of the U.S.
criminal statutes enumerated in 22 CFR 120.27 since the effective date of the Arms Export Control Act, Public Law 94-329, 90 Stat. 729 (June 30,
1976); or is ineligible to contract with, or to receive a license or other approval to import defense articles or defense services from, or to receive an
export lisence or other approval from any agency of the U.S. Government.

22 CFR 126.13 Certification (Select one)
I am authorized by the applicant to certify that the applicant and all the parties to the transaction can meet in full the conditions of 22 CFR 126.13 as
listed in Block 26.
I am authorized by the applicant to certify to 22 CFR 126.13. The applicant or one of the parties of the transaction cannot meet one or more of the
conditions of 22 CFR 126.13 as listed in Block 26. A request for an exception to policy is attached.
I am not authorized by the applicant to certify the conditions of 22 CFR 126.13 as listed in Block 26. The applicant and all the parties to the
transaction can meet in full the conditions of 22 CFR 126.13 as listed in Block 26. Please see the attached letter for such certification.
I am not authorized by the applicant to certify the conditions of 22 CFR 126.13 as listed in Block 26. The applicant or one of the parties of the
transaction cannot meet one or more of the conditions of 22 CFR 126.13 as listed in Block 26. A letter of such certification and request for an
exception to policy is attached.

Compliance with 22 CFR 130 (Select the appropriate box)
This transaction does not meet the requirements of 22 CFR 130.2.
This transaction meets the requirements of 22 CFR 130.2. The applicant or its vendors have not paid, nor offered, nor agreed to pay, in respect
of any sale for which a license or approval is requested, political contributions, fees or commissions in amounts as specified in 22 CFR 130.9(a).
The applicant or its vendors have paid, or offered or agreed to pay, in respect of any sale for which a license or approval is requested, political
contributions, fees or commissions in amounts as specified in 22 CFR 130.9(a). Information required under 22 CFR 130.10 is attached.
I am not authorized by the applicant to certify the conditions of 22 CFR 130.9(a). Please see the attached letter for such certification.
Signature

Signature

27. Foreign Person Applicant Statement
I,

, a foreign person and not a DDTC registered person hereby apply for approval to complete the transaction above;

warrant the truth of all statements made herein; and acknowledge, understand and will comply with the provisions of Title 22 CFR 120-130, and any
conditions and limitations imposed. I have attached a letter certifying this transaction.
I am authorized by the applicant to certify the following in compliance with 22 CFR 126.13:
(1) Neither the applicant, its chief executive officer, president, vice presidents, other senior officers or officials (e.g., comptroller, treasurer, general
counsel) nor any member of its board of directors is:
(a) the subject of an indictment for or has been convicted of violating any of the U.S. criminal statutes enumerated in 22 CFR120.27 since the
effective date of the Arms Export Control Act, Public Law 94-329, 90 Stat. 729 (June 30, 1976); or
(b) ineligible to contract with, or to receive a license or other approval to import defense articles or defense services from, or to receive an export
license or other approval from any agency of the U.S. Government;
(2) To the best of the applicant's knowledge, no party to the export as defined in Section 126.7 (e) has been convicted of violating any of the U.S.
criminal statutes enumerated in 22 CFR 120.27 since the effective date of the Arms Export Control Act, Public Law 94-329, 90 Stat. 729 (June 30,
1976); or is ineligible to contract with, or to receive a license or other approval to import defense articles or defense services from, or to receive an
export lisence or other approval from any agency of the U.S. Government.

22 CFR 126.13 Certification (Select one)
I am authorized by the applicant to certify that the applicant and all the parties to the transaction can meet in full the conditions of 22 CFR 126.13 as
listed in Block 27.
I am authorized by the applicant to certify to 22 CFR 126.13. The applicant or one of the parties of the transaction cannot meet one or more of the
conditions of 22 CFR 126.13 as listed in Block 27. A request for an exception to policy is attached.
I am not authorized by the applicant to certify the conditions of 22 CFR 126.13 as listed in Block 27. The applicant and all the parties to the
transaction can meet in full the conditions of 22 CFR 126.13 as listed in Block 27. Please see the attached letter for such certification.
I am not authorized by the applicant to certify the conditions of 22 CFR 126.13 as listed in Block 27. The applicant or one of the parties of the
transaction cannot meet one or more of the conditions of 22 CFR 126.13 as listed in Block 27. A letter of such certification and request for an
exception to policy is attached.

DS-6004, Page

4 of

3

Case No.

CONDITIONS OF ISSUANCE AND TRANSFER PROCEDURES
1. This license is issued under the conditions cited in 22 CFR 120-130, including any provisos as applicable to the specific license authorization.
2. The issuance of a license for the export/re-export of hardware does not authorize the transfer of any technical data.
3. The issuance of this license does not release the applicant, or anyone acting on their behalf, from complying with other requirements of U.S. law and
regulations.
4. No transfer of title is authorized to occur during temporary export.
5. Access to the defense article by foreign persons shall only be in accordance with and for the purpose identified on this license or the original license as
applicable.
6. Licenses for the temporary export of an aircraft or vessel: The applicant when using this license agrees that during its temporary export the aircraft/vessel
will remain demilitarized and the applicant will maintain the same certification or registry of entry. Also, the aircraft/vessel during its temporary export cannot
be used in any activities (e.g., military activities and transport of USML articles) that are not authorized in this license or by a separate license or exemption
under appropriate USG regulations.
7. The prior written approval of the Department of State, Directorate of Defense Trade Controls, must be obtained before USML articles exported from the
United States using a license or other approval, to include an ITAR exemption, may be resold, transferred, diverted, transshipped, reshipped, re-exported to, or
used in any country, or by any end user or for any end use, other than that described on the license or other approval.

Previous Authorization for
Export from the U.S.

DS-6004, Page

Continuation of Block 18

a. by license no(s):

b. by agreement (technical assistance or manufacturing aggreement) no(s):

c. by ITAR Citation:

d. unknown or other. A reason/explanation follows:

DS-6004

3 of

3

DS-60

Subsidary Information under Block 5 of the DS-6004
Name

Attention
Address
City
State
Telephone #

DS-6004

State

ZIP Code
Ext

of

3