Form DS-4100 Iran Program Grants

U.S. Department of State

IRAN PROGRAM GRANTS

OMB APPROVAL NO.1405-0176
EXPIRATION DATE: xx/xx/xxxx
ESTIMATED BURDEN: 1 HOUR

Bureau of Near Eastern Affairs (NEA)
Bureau of Democracy, Human Rights and Labor (DRL)
Bureau of Educational and Cultural Affairs (ECA)
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
AUTHORITIES: The information is sought pursuant to effectuate the goals of ections 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.
PURPOSE: The information solicited on this form 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.
ROUTINE USES: The information on this form may be shared with 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.More information on the Routine Uses for the system can be found in the System of Records Notice State-08,
Educational and Cultural Exchange Program Records.
DISCLOSURE: Providing this information is voluntary. Failure to provide the information requested on this form 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 currently 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: NEA/IR 2201 C Street NW, Room 1245, Washington, DC 20520.
DS-4100
xx-xxxx