Form DHS Form 10006 DHS Form 10006 Application for Developmental Testing and Evaluation Des

OMB Control No. 1640-0001
Expires: 03/31/2013

APPLICATION FOR SAFETY ACT DEVELOPMENTAL
TESTING AND EVALUATION DESIGNATION
To encourage the development of anti-terrorism technologies, the SAFETY Act is
implementing regulations to provide for the issuance of Developmental Testing and
Evaluation Designations (DT&E Designations) for promising anti-terrorism technologies.
DT&E Designation facilitates the deployment of these anti-terrorism technologies in the
field either for testing and evaluation purposes or in response to exigent circumstances by
providing, on a limited basis, the liability protections offered by the SAFETY Act.
Depending on the nature and/or the maturity of the Technology, operational or other
conditions may be included among SAFETY Act liability protections. DT&E Designations
are intended to provide the Department with added flexibility in making the SAFETY Act
liability protections available to firms that are developing promising anti-terrorism
technologies.

(DT&E Designation Form on following page)

Privacy Act Notice: DHS Authority to Collect This Information: 6 U.S.C. §§ 441–444 (the “SAFETY Act”) and 6 C.F.R. Part 25, 71 Fed. Reg.
33147, 33159. Principal Purposes: DHS collects telephone numbers, addresses, and financial and insurance information for the purpose of
contacting individuals seeking liability protections on issues related to the application for SAFETY ACT developmental testing and evaluation
designation process. Routine Uses and Sharing: In general, DHS will not use this information for any purpose other than DHS personnel
contacting the individual. However, DHS may release this information of an individual on a case-by-case basis as described in the S&T SAFETY Act
System of Records Notice (SORN), which can be found at: www.dhs.gov/privacy. Disclosure: Submission of this information is voluntary and an
individual may opt not to provide the requested information or to provide only some of the information DHS requests. If an individual chooses to opt
not to provide some or all of the requested information, DHS may not be able to process the individual’s request.
PRA Burden Statement: An agency may not conduct or sponsor an information collection and a person is not required to respond to this
information collection unless it displays a current valid OMB control number and an expiration date. The control number for this collection is 16400001 and this form will expire on 03/31/2013. The estimated average time to complete this form is 60 hours per respondent. If you have any
comments regarding the burden estimate you can write to Department of Homeland Security, Science and Technology Directorate, Washington, DC
20528.
DHS Form 10006 (10/06)

APPLICATION FOR SAFETY ACT DEVELOPMENTAL TESTING
AND EVALUATION DESIGNATION
APPLICATION TYPE
TE1. Type of Application. This application is a(n) (choose one):
Initial Filing
Application following a Pre-Application Consultation Application ID
#:__________
Resubmission of a Previous Application. Application ID #:
__________________
TE1.1. Public Web site Listing
If your Technology is awarded SAFETY Act coverage, you have the
opportunity to be listed on the SAFETY Act Web site as a Designated Seller
of anti-terrorism technologies. [For example, if you apply for Designation
and Certification and receive Designation, your Technology will be listed
under Designated Technologies. Or, if you are granted DT&E Designation,
regardless of which protection you applied for, you will be so listed on the
Web site. Note: By statute, all Certified Technologies will be displayed in the
Approved Products List for Homeland Security on the Web site.]
I wish to have this Technology listed on the public Web site under the
appropriate classification.
I do not wish to have this Technology listed on the public Web site under the
appropriate classification.
REGISTRATION INFORMATION
TE2. Registration Status (choose one):
My initial registration is included with this application.
I am updating or correcting previous registration information.
My previously provided registration information is still accurate.
TE2.1. Seller Name: ______________________________________________________
OVERVIEW OF THE ANTI-TERRORISM TECHNOLOGY
TE3. Non-proprietary Summary
TE3.1. Name of your Technology: ___________________________________________
TE3.2. Company and Technology Description. Provide an overview of your
company, including the place of incorporation, a description of your
DHS Form 10006 (10/06)

business, and a brief, two line description of the Technology that is the
subject of this application that is appropriate for public viewing.
TE4.

Summary of your Technology. Please provide a brief (no more than two page)
description of your Technology, listing all components that you wish to have
evaluated as part of your SAFETY Act application. . If your Technology is a
product or device, please describe the Technology in detail, including its principal
elements, systems, and components. If your Technology is a service, please
describe the nature of the service, the actions, activities, planning, training, and/or
expertise involved in providing the service and how the service is designed to
counter terrorist threats.
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________

DEVELOPMENTAL TESTING AND EVALUATION DESIGNATION
Respond to all items in this section in one attachment to this application.
Additional supporting material may be attached as an appendix to your
application.
TE5.

Description of your Technology. One of the most important parts of the
application process is defining the scope of your Technology. In this section,
define your Technology with a sufficient degree of specificity. This description
will serve as the basis for the Department’s analysis of your Technology for
SAFETY Act purposes. The content of the response you provide in this section,
together with any additional information you may be asked to provide, may be
used to finalize the definition and scope of your Technology as it will appear in a
Developmental Testing and Evaluation Designation.
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________

DHS Form 10006 (10/06)

TE6.

Nature of Test Scenario. Please provide an outline of the test plan for the subject
Technology. The outline may include the nature of the test, the entity that will
conduct the test, relevant time frames, proposed test methodology, location of the
test, summary rationale for conducting the test, and any other information that
you wish to provide.

TE7.

Deployment and Operation. Describe the sequence of steps involved in
deploying and operating your Technology.

TE8.

Magnitude of Risk. Please provide an assessment of the magnitude of risk to the
public from the type of terrorist activities your Technology would counter. Please
describe, to the extent practicable, the scope of the injury, property and other
damage, economic loss, loss of life, or other harm that could result from such
terrorist activity. Please describe how the Technology has been deployed to date
and how it can counter terrorist activities. If the Technology has not yet been
deployed, summarize the prototype testing or other testing that has been
conducted to date.

TE9.

Please describe how your plans for selling, deploying, or maintaining your
Technology would be affected if the Department does not issue Developmental
Testing and Evaluation (DT&E) Designation. Please describe how the
Technology will be deployed in the future if SAFETY Act DT&E Designation is
issued.

TE10. Effectiveness and Utility. Provide information supporting the potential for your
Technology to be effective in countering potential acts of terrorism.
If POCs are provided as sources of information or testimonials, check below to
indicate that you have contacted them and that they are expecting to hear from
DHS related to your Technology. Also, indicate below what information we should
expect from each POC.
The POCs are expecting contact from DHS. The information the POC can
provide or verify is:
____________________________________________________________
____________________________________________________________
____________________________________________________________
TE11. Summarize your Technology’s qualifications for SAFETY Act Developmental
Testing and Evaluation Designation. Include any other information the
Department should consider in evaluating your anti-terrorism technology. Please
include information relating to interest by governmental entities in testing or
provisionally deploying your Technology.
If POCs are provided as sources of information or testimonials, check below to
indicate that you have contacted them and that they are expecting to hear from

DHS Form 10006 (10/06)

DHS related to your Technology. Also, indicate below what information we should
expect from each POC.
The POCs who are expecting contact from DHS. The information the POC
can provide or verify is:
____________________________________________________________
____________________________________________________________
____________________________________________________________
TE12. Insurance Data
If POCs are provided as sources of information or testimonials, check below to
indicate that you have contacted them and that they are expecting to hear from
DHS related to your Technology. Also, indicate below what information we should
expect from each POC.
The POCs are expecting contact from DHS. The information the POC can
provide or verify is:
____________________________________________________________
____________________________________________________________
____________________________________________________________
TE12.1. Please provide the information below for any and all current liability
insurance policies that you hold and are available to satisfy otherwise
compensable third-party claims arising out of, relating to, or resulting from
an act of terrorism were your Technology deployed in defense against,
response to, or recovery from such an act:
a. Primary Named Insured (as it appears on your insurance policy).
b. Additional named insured relevant to the Technology Sellers.
c. Type of policy(ies) (e.g., Comprehensive General Liability, Errors and

Omissions, Aviation, Product Liability, SAFETY Act Liability, etc.) and any
relevant endorsements.

d. Policy Dates. (Start and end)
e. Insurer.
f. Per-occurrence limits.1
g. Aggregate limits.

1 Please indicate whether the policy(ies) has a different limit or deductible/self-insured retention for

terrorist acts than the general policy limit and, if so, provide both.
DHS Form 10006 (10/06)

h. Annual Premium(s).2
i.

Deductible(s) or Self-insured retentions.

j.

Exclusions (please note and explain any pertinent insurance exclusions or cancellation
terms that would potentially dilute or eliminate the availability of coverage of any of the
policies identified in subparagraph “c” above).

k. Does your insurance policy(ies) cover the type of developmental test and

evaluation and activities anticipated in this application? If yes, please
describe.
l.

Please describe the type and limits of terrorism coverage for this policy.
Please elaborate on the applicability of the policies identified in
subparagraph “c” to address the foreseeable risks associated with the
deployment of the Technology including those risks arising from the
deployment of the Technology in advance of or response to an act of
terrorism. Please also indicate whether the identified policy(ies) provides
coverage under the Terrorism Risk Insurance Act (TRIA) of 2002, as
amended, or other insurance policy(ies) provisions or endorsements.

m. Please describe whether the relevant policy(ies) covers SAFETY Act claims

and whether the policy(ies) has a dedicated limit that applies to SAFETY
Act claims only or has a shared limit (i.e., shared with non-SAFETY Act
claims). Please indicate whether you have received a written interpretation
letter from either the carrier or insurance broker indicating whether the
policy covers SAFETY Act claims; if so, please provide a copy of such
document.
n. Is your Technology indemnified by a third-party organization or entity

(including the U.S. Government) for the test and evaluation described in this
application? If so, please describe the key terms and conditions and limits of
indemnification.
TE12.2. Unavailability of Insurance
a. If you do not currently carry insurance for the Technology that would be
applicable in the event of an act of terrorism, please indicate the reasons. If
you have attempted to purchase insurance but it is not available on the
world market, please indicate the specific and related inquiries you have
made. (You may submit written communications from insurance companies
or brokers explaining why your Technology cannot be insured.)
b. If you have endeavored to purchase insurance but have not done so because
you have concluded that the cost of insurance premiums would

2 Insurance premium: If possible, please indicate what percentage of the premium is allotted to coverage

for acts of terrorism.
DHS Form 10006 (10/06)

unreasonably distort the price of the Technology, please describe those
efforts to find appropriate insurance and state why you have concluded that
the cost of insurance for your Technology would unreasonably distort its
sales price. In this context, you may need to provide an explanation with
relevant documentation (e.g., insurance quotes with limits, premiums,
exclusions, and other key items plus other relevant financial and market
data). Note: The Department recognizes that the discussion of
requisite insurance with an Applicant may require a number of
communications while an application is pending. Thus, the question
of whether a given premium would “distort the sales price” of a
Technology might not arise when the application is submitted. If the
question does arise later in the process, the Applicant may submit
appropriate information at that time.
TE12.3. Insurance Point of Contact
Provide a point of contact, including telephone number and e-mail address
for someone authorized to discuss your company’s insurance information
with the Department. This point of contact may be the same person
identified in your registration statement and may be your counsel, insurance
expert, or any other person with appropriate information.
TE12.4. Revenue Projection
In order for us to determine the amount of insurance that would not
unreasonably distort the sales price of your Technology, we need you to
provide us with three (3)-year projected (prospective) revenue estimates for
your Technology - all assuming that your Technology is approved under the
SAFETY Act. The three-year period should include your current fiscal year,
if incomplete, and two subsequent years.
If you do not have current year sales for your Technology, please provide us
with three (3)-year projected revenue data.
The revenue data needs only to pertain to your Technology and the numbers
need only be summarized data (that is, we do not require the revenue
sources to be itemized). The revenue data should be matched with
summarized cost data (e.g., cost of goods sold); as with the revenue data, we
do not require breakdown of data by cost centers.

DHS Form 10006 (10/06)

TE12.5. Deployment
Please establish how the deployment of your Technology as an antiterrorism technology would expose you to extraordinarily high liability and
what this liability might be. This can be accomplished by developing a
plausible scenario that establishes how the Technology could be the
proximate cause of third-party claims in the event of an act of terrorism.
Please make the scenario and third-party liability claims specific to the
deployment and use of your Technology.
TE13. Financial Data
Certain financial information regarding your company and projected/prospective
technology revenue is particularly relevant to the application process. This is
especially true when questions arise as to whether insurance costs for specified
coverage limits unduly distort the price of your Technology. We may request
additional information from the Applicant, if necessary, during the application
process.
TE13.1. Please provide a copy of the Seller’s financial statement for the most recent
fiscal year. For public companies, the most recent SEC annual report (Form
10-K) and SEC quarterly report (Form 10-Q), together with any
amendments thereto, should suffice. For non-publicly traded companies,
you may choose to include the following information for the most recent
fiscal year: income statement, statement of cash flow, and balance sheet as
well as pro forma financial statement. OSAI will seek additional and more
specific information only when necessary for a particular application.

ADDITIONAL ATTACHMENTS

Provide all supporting documentation.

DHS Form 10006 (10/06)

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

Notary Public:

_____

day of

_____________________

___________________________________________________

My Commission Expires on:

DHS Form 10006 (10/06)

County of: __________________________

________________________________________

Instructions for Completing the Developmental Testing and
Evaluation Designation Application Form:
Application Type
Item TE1. Type of Application
If you have not previously filed an Application for SAFETY Act liability protections
for this Technology or have not filed a request for Pre-Application Consultation,
check “Initial Filing.”
If you have filed a request for Pre-Application Consultation regarding this
Technology but have not previously filed an Application for SAFETY Act liability
protections, check the second box: “Application following a Pre-Application
Consultation.”
If you have previously applied for SAFETY Act liability protections for this
Technology, check the third box: “Resubmission of Previous Application.” This case
applies if any previous applications for this Technology were withdrawn, found to be
incomplete, or were declined. Previously incomplete or declined applications will not
affect the evaluation of your current application; this information is requested for
administrative and record-keeping purposes only.

Registration Information
Item TE2. Registration Information
Please check the appropriate box relating to your registration status.
Item TE2.1. Name of Applicant/Seller
Enter your Seller name as listed on your registration form.

Overview of the Anti-Terrorism Technology
Item TE3. Non-Proprietary Summary
Item TE3.1. If this is the first application for this Technology, assign a name to your
Technology. This is the name that will appear on Developmental Testing and
Evaluation Designation that may be issued.
Item TE3.2.
The purpose of this item is to help the Department recognize potential conflicts of
interest and to avoid disclosing your application information to inappropriate
evaluators. The Department is committed to protecting your sensitive business data
from improper disclosure.
Provide a brief description of your company, including place of incorporation, a
description of your business, and the Technology that is the subject of the
DHS Form 10006 (10/06)

Application. When describing your company, focus on identifying any affiliates that
will be involved with your Technology (e.g., parent companies, subsidiaries, joint
venture partners, holding companies, etc.). When describing your Technology, focus
on providing information that will help the Department identify which Subject
Matter Experts (SMEs) would be best qualified to evaluate your Technology. This
description should be no more that two sentences long and should be appropriate for
placement on a public Web site if your application is approved.

The purpose of the company description and Technology description is to
help the Department recognize potential conflicts of interest and avoid
disclosing your application information to inappropriate evaluators. The
Department is committed to protecting your sensitive business data from
improper disclosure. Do not include any sensitive or proprietary information
in this summary. If you wish to include information on substantially similar
QATTs or provide information regarding who your major competitors are with
respect to the subject Technology, you may do so.
Item TE4. Nature of Your Technology
Please describe the nature of your Technology in two pages or less. The SAFETY
Act applies to a broad range of anti-terrorism technologies. In your response to the
question please describe whether your application is for an anti-terrorism product,
service, combination of products and services, information technology, or some other
form of intellectual property. If your Technology is a product or device, please
describe the Technology in detail, including its principal elements, subsystems, and
components. If your Technology is a service, please describe the nature of the
service, the actions, activities, planning, training, and/or expertise involved in
providing the service and how the service is designed to counter terrorist threats. If
your Technology is an “integrator” of various products, services, or legacy systems,
indicate how the Technology will integrate the various component parts.

Developmental Testing and Evaluation Designation
Under the SAFETY Act, the Secretary of the Department of Homeland Security will
consider enumerated, non-exclusive criteria when evaluating a Technology for
potential Developmental Testing and Evaluation Designation. The Act gives the
Secretary discretion in determining whether to issue a Developmental Testing and
Evaluation for a Technology.
This section of the Application requests information that is necessary to evaluate
your Technology. Attach your responses to this section as one attachment. Not all
questions will be applicable to all types of technology. If a particular request or
question does not seem relevant to your Technology, do not leave a question blank
or merely refer to a previous response; explain why you do not think it is relevant in
your response for that item.

DHS Form 10006 (10/06)

This section must be presented in a narrative format, referring to each section below.
The ATT Details section should be written so that the reader may clearly understand
what your Technology is, what it does, and how it operates. The narrative sections
should consist of your claims about the capabilities, and effectiveness of your
Technology in an anti-terrorism context. It is important that all of your claims are
supported by relevant documentation in some manner. Depending on the nature of
your technology, e.g., product vs. service, that support would normally include such
items as case examples, test data, audits, assessments, reports, specification sheets,
operating manuals, instructors manuals, performance reports, procedural manuals,
and the like. It is vital that you cross reference the supporting documentation to each
claim you make in order that our reviewers understand what material you wish us to
evaluate. You should provide a Table of Contents listing as a separate attachment
which itself, lists your numbered attachments or exhibits.

Item TE5. Description of your Technology
One of the most important parts of the application process is precisely defining the
scope of your Technology for evaluation and Designation. In order for the Secretary
to issue liability protections to your Technology, you must define with specificity
what that Technology is – that is, what you provide to your customers when you sell
that Technology, what it does, how it works, and what aspects of it are invariable
from deployment to the next. Note: embellishments, marketing materials, and
elements which cannot be substantiated in the rest of the application should not be
included. In response to this section, include the following:
• Company name, business structure, additional sellers, and states of
incorporation, as applicable;
• Name of the Technology;
• Nature of the Technology;
• Purpose or intent of the Technology;
• Description of how the Technology works;
• A statement of where the Technology is intended to be utilized, e.g., in the
private sector, for the Federal government, for the military, etc.;
• A brief description (no more than two lines) of the type of terrorist attacks or
attempted terrorism acts the Technology is expected to counter; and,
• The principal elements, systems, or components provided to customers
(indicating, which components, if any, are optional)
The above elements as you provided in your Application will be translated into a
concise description by the Office of SAFETY Act Implementation, as in the
following example:
(Name of company, and any subsidiaries), a (State of Incorporation) company, provides the
(Name of technology) which is designed to (Purpose of the technology). (Name of Technology)
e.g., does this by (Briefly describe how it works) for ( Place of deployment or type of customer).
DHS Form 10006 (10/06)

The Technology is used for the following anti-terror purpose(s) (type of threat). The Technology
includes the following elements:
• (list e.g., hardware and software )
• (list – e.g., integration services)
• (list- e.g., training and consultation)
After developing your description, you should refer back to key sub-components or
services when developing support for your ability to provide each part of your
Technology. Your description should answer the following questions:
• How and where may your Technology be used? If your Technology is a
device, address what training, if any, is necessary to use your Technology. If
your Technology is a service, describe what types of facilities you might serve
and how your Technology is tailored to providing anti-terrorism services at
those locations.
• Explain the underlying principles or properties that allow your Technology to
perform its functions and achieve its purposes. If your Technology consists
of devices, explain the operational principles of those devices. If your
Technology consists of services, explain how those services are implemented
to ensure consistent quality wherever they are delivered and whether these
services conform to recognized industry standards. If your Technology
consists of software, explain the key features and algorithms. If your
Technology consists of some other kind of product, explain how you produce
that product. This information will help the Department understand the
precise scope of the Technology for which you are applying for SAFETY Act
coverage.
• What are the important elements that make up your Technology? That is,
what are the component processes, devices, software, or other contributing
activities and technologies that will be included in your specification? How
are they defined or delineated? Be aware that any ancillary components of
your Technology that are identified in your specification (e.g., manuals,
training, maintenance, etc.) should be supported in subsequent sections by
sufficient information to evaluate them. What parts of your business, if any,
are explicitly not included in this specification for purposes of this application?
Examples of component systems and activities of your Technology might
include:
– Equipment
– Software
– Software design
– Personnel training and qualifications
DHS Form 10006 (10/06)

–
–
–
–
–
–
–
–
–

Staffing
Algorithms
Consulting services
Systems integration services
Decision support systems or services
Maintenance contracts
Periodic upgrades, post-deployment reviews
Testing services
Quality control features

If your Technology is primarily service-based, focus on describing the various
activities and sub-processes that contribute to the overall delivery of your service(s).
This information will help the Department understand the precise scope of your
Technology.
In addition to describing what you do, you should also describe any elements,
processes, or activities that complement or interact with your Technology but that are
not specifically part of the Technology in this application and may be supplied by the
end-user. These might include other technologies you sell, activities performed by
your customers, technologies provided by other vendors, or parts of the public
infrastructure. This information will help the Department understand the precise
scope of Technology you are establishing in this specification. If your Technology
helps to integrate new components with legacy systems, please indicate that.

Item TE6. Nature of Test Scenario
Please provide us with a test plan or a detailed test strategy. The test plan or strategy
should include the nature of the test (e.g., field study, lab study, pilot program
participation), the entity that will conduct the test (e.g., internal, private third-party,
Government sponsor), time frame and discussion of the adequacy of the length of
the test, proposed test methodology, location of the test, and summary rationale for
conducting the test. Please include information relating to Government or
Government-sponsored testing of your Technology. Your test strategy or plan
should also address the expected outcomes of the test, how the test metrics collected
will demonstrate the effectiveness of your Technology, and the expected test product
(report, briefing, etc.).
Keep in mind that the purpose of a DT&E Designation is to allow you to collect
information that will support the effectiveness of your Technology in a Designation
application. What do you expect to be able to deliver to the Department at the end
of your DT&E Designation that will allow us to make a determination about the
effectiveness of your Technology? If you are providing services or support services,
will you be developing process documents? How will you implement these plans?

DHS Form 10006 (10/06)

Item TE7. Deployment and Operation
Describe the steps involved in the course of developing, producing and providing
your Technology to a customer. Using the Technology Description developed above,
you should provided documented support of your capability to provide all elements
of your Technology in these areas.
It is useful to begin by describing the sequence of steps involved in providing your
Technology to a customer, from initial contact to final deployment. Focus your
description on the process of producing and deploying your Technology, as opposed
to the end result or the nature of any specific tangible deliverable. Where possible,
include the estimated time required for each activity or step.
If your Technology involves physical products, your discussion might include
elements such as:
• Manufacturing capabilities (where will the Technology be manufactured, are
facilities in place, is there a manufacturing plan in place?)
• Production, including quality assurance, factory acceptance tests,
manufacturing standards, and the like.
• Installation and configuration plans, to include site acceptance tests
• Operation plans, operator instructions, and the like
• Training, including any user manuals or terms of use
• Maintenance and any maintenance records
• Monitoring
• Upgrade policies
• Warranties and service contracts
• Post-deployment quality control
Where your Technology includes software or information technology, please include
information such as:
• Software lifecycle development plans, including any verification, validation,
and accreditation (VV&A)
• Software upgrade policies
• Network architecture information
• Network security information
• Network stress testing
• Customer input into user access
Where your Technology involves services, your description might include (as
relevant):
• Customer requirements analysis
• Determining scope of effort
DHS Form 10006 (10/06)

• Operation plans, including items such as post orders, statements of work, and
management plans
• Implementation plans
• Post-delivery support
• Process and Procedure Documents
• Quality Control, to include any independent or third-party audits, managerial
oversight at the local and corporate level, policy revisions, lessons learned, etc.
Please see “Additional Attachments” below for instructions on supporting
documents and classified materials submission.

Item TE8. Magnitude of Risk
Please provide an assessment of the magnitude of risk to the public from the type of
terrorist activities your Technology would counter. Your response should identify
the types or categories of potential terrorist activities your Technology is intended to
address. Your response should also present, to the extent practicable, estimates of
the scope of the injury, property or other damage, economic loss, loss of life, or other
harm, including financial harm, that could result from such terrorist activity.
Additionally, please also describe how the Technology has been deployed to date, if
applicable to counter terrorist threats.

Item TE9. Impact of SAFETY Act Designation
Please describe how your plans for selling or deploying your Technology would be
affected should the SAFETY Act’s system of risk and litigation management not be
made available. Please describe how the Technology will be deployed in the future if
SAFETY Act Developmental Testing and Evaluation Designation is issued.

Item TE10. Effectiveness and Utility
You should support each element, sub-component, or model listed in the Technology
Description provided in response to TE.5. If you apply the same information to
multiple elements, sub-components, or models, please indicate why this is reasonable.
The information you provide here should include the primary material supporting
your belief that your Technology can be a valuable counter terrorism tool. The kind
of documentation you provide will depend on the nature of your Technology.
If your Technology is primarily a device or software product, then your
documentation should emphasize available developmental and operational test data
that indicate the likely operating performance of that device or software. This could
include performance in past deployments, independent test results, field tests (e.g.
performance against simulated attacks), internal test data, customer studies, scientific
studies of the techniques involved, industry reports, Government or military
publications, or any other documentation that suggests or supports the potential
usefulness of your Technology. Please attach copies of any such reports,
publications, or evidence by using the additional attachment sections that would
DHS Form 10006 (10/06)

facilitate analysis and evaluation of your Technology by Subject Matter Experts
(SMEs).
If your Technology is primarily a service, your documentation should emphasize the
quality of the process whereby that service is delivered and include any available
evidence of successful similar past deployments. In particular, you should provide or
cite information that documents any of the following:
•
•
•
•
•

The quality of the services you provide.
Your specification for the processes you use to provide those services.
The repeatability of your processes for providing those services.
Your methods for monitoring your adherence to your processes.
Your means for measuring the success of a particular deployment of your
services.
• Your reputation as a provider of these services.

The Department will not ordinarily conduct any tests of your Technology for
purposes of SAFETY Act evaluation or compare your Technology directly to other
similar technologies. Reviewers will evaluate your Technology against the criteria for
Developmental Testing and Evaluation Designation primarily on the basis of the
information you provide. Accordingly, the information you provide in response to
this question should be as comprehensive as possible.
Please provide an overview narrative of your Technology, including references and
summaries of supporting documentation. If you reference any material that is not
publicly available, it should be included as an attachment to your application. If you
refer to information provided elsewhere in your application, cite it by internal title,
item number, and the name of the attachment. Even though your entire application
will be treated as confidential, you should (but are not required to) specially mark
those portions of your application which contain proprietary and/or business
confidential information.
Please see “Additional Attachments” below for instructions on supporting
documents and classified materials submission.
If POCs are provided as sources of information or testimonials, please indicate that
you have contacted them and that they are expecting to hear from DHS related to
your Technology. Also, please be advised that:
1. The SAFETY Act may make contact with persons that you list as having
information to support the claims in your Application; however it is your
responsibility to make sure that you have provided all information to
support your Application at the time of submission. Do not simply include
a listing of your customers for DHS to contact. We suggest that you obtain
written testimonials from your customers.

DHS Form 10006 (10/06)

2. If you believe that third-parties will be able to provide additional
supporting information for which you do not have access (such as for
example, classified reports, audits, vulnerability assessments, or other
reports or data), remember to:
a) Be sure that the contact information you provide to us is
current.
b) Notify your references that you have submitted a SAFETY Act
application and that we may contact them.
c) Make sure that you are giving us the contact that will be able to
provide the best information on the nature of the past sale or
deployment, and on how your technology actually worked.
d) You may also supply contact information for third-parties, e.g.,
government officials, who might supply customer testimonials.
These individuals should be able to supply actual knowledge of
how your technology works and of its utility. We suggest that
you obtain this information in writing.
e) For procurements, list the name and contact information for
the procurement officer or similar person in charge of the
contract, proposal, or Request for Proposal.

Item TE11. Summary of Developmental Testing and Evaluation
Qualifications
If you wish, you may use this item to summarize in broad terms why you believe your
Technology qualifies for SAFETY Act Developmental Testing and Evaluation
Designation. Please provide whatever additional information that would be helpful
to the Department in analyzing and evaluating your Technology. If you are providing
attachments, please provide a Table of Contents.
If POCs are provided as sources of information or testimonials, please indicate that
you have contacted them and that they are expecting to hear from DHS related to
your Technology. Also, indicate what information we should expect from each POC.

Item TE12. Insurance Data
Document any and all current insurance coverage that would be available to satisfy
otherwise compensable third-party claims arising out of, relating to, or resulting from
an act of terrorism were your Technology deployed in defense against, response to, or
recovery from such act and found to have caused harm. Please state whether such
policy includes TRIA coverage, as amended, or other insurance policy(ies) provisions
or endorsements that cover acts of terrorism. Please specify any relevant exclusions
or cancellation provisions that would limit the availability of the current policies to
satisfy third-party claims.
If POCs are provided as sources of information or testimonials, please indicate that
you have contacted them and that they are expecting to hear from DHS related to
your Technology. Also, indicate what information we should expect from each POC.
DHS Form 10006 (10/06)

Item TE12.1. Current Insurance
For item TE12.1.a, provide the name of the company identified as the primary
insured for the relevant current policy. If you are an additional insured instead of the
primary policy holder, please identify the primary insured and each other firm
identified as an additional named insured in item TE12.1.b.
In item TE12.1.k., specify the type of terrorism coverage that is provided under the
specified policy(ies) (e.g., Terrorism Risk Insurance Extension Act, as amended, other
coverage, no terrorism exclusion). Please specify the overall and per-occurrence
limits that would apply to the terrorism coverage.
Item TE12.2. Unavailability of Insurance
The SAFETY Act provides that a Seller may not be required “to obtain liability
insurance of more than the maximum amount of liability insurance reasonably
available from private sources on the world market at prices and terms that will not
unreasonably distort the sale price of Seller’s anti-terrorism technologies.” If you are
unable to obtain appropriate insurance, please provide information concerning your
attempts to obtain insurance coverage for your Technology (e.g., written
communications from insurance companies or brokers explaining why your
Technology cannot be insured). If insurance is available for terrorism events but at
rates which would distort the sales price of your Technology, document the price of
that insurance and provide information to support how it would affect the price of
your Technology. You may wish to contact OSAI with questions concerning what
information would be most helpful to provide in response to this item.
Note: The Department recognizes that the discussion of requisite insurance
with an Applicant may require a number of communications while an
application is pending. Consequently, the question of whether a given
premium would “distort the sales price” of a Technology might not arise when
the Application is submitted. If the question does arise later in the process,
the Applicant may submit appropriate information at that time.
Item TE12.3. Insurance Point of Contact
Provide a point of contact, including telephone number and e-mail address for
someone authorized to discuss your company’s insurance information with the
Department. This point of contact may be the same person identified in your
registration statement and may be your counsel, insurance expert, or any other person
with appropriate information.
Item TE12.4. Revenue Projection
In order for us to determine the amount of insurance that would not unreasonably
distort the sales price of your Technology, we need you to provide us with three (3)year projected (prospective) revenue estimates for your Technology – all assuming

DHS Form 10006 (10/06)

that your Technology is approved under the SAFETY Act. The three-year period
should include your current fiscal year, if incomplete, and two subsequent years.
If you do not have current year sales for your Technology, please provide us with
three (3)-year projected revenue data.
The revenue data needs only to pertain to your Technology and the numbers need
only be summarized data (that is, we do not require the revenue sources to be
itemized). The revenue data should be matched with summarized cost data (e.g., cost
of goods sold); as with the revenue data, we do not require breakdown of data by cost
centers.
Item TE12.5. Deployment
Please establish how the deployment of your Technology as an anti-terrorism
technology would expose you to extraordinarily high liability and what this liability
might be. This can be accomplished by developing a plausible scenario that
establishes how the Technology could be the proximate cause of third-party claims in
the event of an act of terrorism. Please make the scenario and third-party liability
claims specific to the deployment and use of your Technology.

Item TE13. Financial Data
Certain financial data may be used in for analyzing the appropriate amount of
insurance coverage for your particular Technology. This is particularly true when
questions arise as to whether insurance costs unduly distort the price of your
Technology. Accordingly, you may be asked to provide certain financial data to
OSAI as part of your application. Even in such a case, OSAI will not demand
financial information when it is not necessary for a particular application, and will not
disclose sensitive or proprietary information outside the application process.
Applicants may wish to provide financial data relating exclusively to the Technology.
Item TE13.1. It may be helpful to attach your latest financial statement. If you are a
public company, your latest SEC 10-K annual report and SEC 10-Q quarterly report
together with any amendments thereto should suffice. If your company is not
publicly traded, you may include the following information for the most recent fiscal
year: income statement, statement of cash flow, balance sheet, and pro-forma
financial statement. OSAI may seek additional and more specific information but
only when necessary for a particular application.

Additional Attachments
In the process of answering the questions above, you might find it useful to attach
additional documents in support of your answers. These items can be included in
your application by using the “Additional Attachments” feature. When answering the
items above, it is appropriate to refer to attachments by name and or number.
Examples of common attachments might include, but are not limited to, the
following: test reports demonstrating the effectiveness of the Technology, operating
DHS Form 10006 (10/06)

manuals, training manuals, project/program management plans, quality assurance
plans, quality control plans, copies of company certifications, results from pilot
studies, testimonials from customers, and warranties.
Submitting Documents as Attachments:
Documents in support of your Application should be uploaded as Attachments
together with a separate numbered Table of Contents document. Attachments
should be individually labeled and or otherwise clearly identified. For ease of use, we
prefer that documents are uploaded individually, rather than in a “Zip” file. Do not
submit the ATT Details Narrative document in write-protected format since that
information must be accessible to us for use in the creation of OSAI Program
documentation. Ideally, attachments should be cross referenced in your narrative
response, with clear indications of the purpose of the Attachment. It is usually
unnecessary to upload third-party material, such as government training
presentations, regulations or standards documents. You may refer to these
documents in your narrative and provide an open-source link. For additional
assistance in uploading documentation, or for further questions, please call the
SAFETY Act Help Desk.
Submitting classified or sensitive data or information:
In cases where the effectiveness data, e.g., audits or testing, that you wish to have
evaluated is classified or sensitive and is held by a third party; the Department will
attempt to assist you in obtaining this information, however, you MUST facilitate the
transfer of that data to the SAFETY Act office PRIOR to the submission of your
Application. This means that you must notify the custodian of records for your
customer of your Application to the SAFETY Act and that Department requires
access to those records. Once you have completed this step, you must provide the
Department with the name and contact information of the holder of these records.
When a date has been set for the transfer of information, you may submit your
Application. For further assistance call the SAFETY Act Help Desk.
Declaration for Written Submissions
An authorized agent of the Applicant must, in the presence of a Notary, sign and date
this form before submitting it to OSAI. For electronic or Web submissions, follow
the instructions provided at safetyact.gov.

DHS Form 10006 (10/06)