Form DHS Form 10004 DHS Form 10004 SAFETY Act Block Certification

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

SAFETY ACT BLOCK CERTIFICATION APPLICATION
The Secretary may issue Block Certifications at his discretion for anti-terrorism technologies
that meet established performance standards or defined technical characteristics. Sellers of
Technologies that are the subject of a Block Certification may submit a streamlined
application to be afforded the liability protection available under the SAFETY Act. Block
Certification will be published on the SAFETY Act Web site (http://www.safetyact.gov).
Each Block Certification may set forth particular terms and conditions that should be
addressed in the accompanying application to be used in applying for SAFETY Act
protection pursuant to a particular Block Certification.

(Block Certification 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 other identifying information for the purpose of contacting
individuals seeking liability protections on issues related to the SAFETY ACT application 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 50 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 10004 (10/06)

SAFETY ACT BLOCK CERTIFICATION APPLICATION
APPLICATION TYPE
BC1. Type of Application.
I am responding to an announced Block Certification. Reference:
______________ Date issued: ________ Technology Name:____________
Resubmission of a Previous Application for an announced Block Certification.
Previous Application ID #: _______________ Reference: ______________
Date issued: ________ Technology Name:______________
REGISTRATION INFORMATION
BC2. Registration Status (choose one):
I am updating or correcting previous registration information.
My previously provided registration information is still accurate.
BC3. Name of Seller: ____________________________________________________
BC4. Company Description. Provide an overview of your company, including a
description of your business.
BLOCK CERTIFICATION
Respond to all items in this section in one attachment to this application.
Additional supporting material can be attached as an appendix to your
application.
BC5. If any other corporate entity or entities should be identified as an authorized Seller
of the subject Technology in addition to the firm identified in the response to BC3.
above, please identify each entity and the place in which it is organized.
BC6. Provide the Earliest Date of Sale of the Technology for which you are requesting
SAFETY Act coverage.
BC7. Identify the Block Certification to which you are responding by noting the name of
the Block Certification and the date it was issued. Reference any special terms or
conditions presented in the referenced Block Certification.
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.
DHS Form 10004 (10/06)

The POCs are expecting contact from DHS. The information the POC can
provide or verify is:
______________________________________________________________
______________________________________________________________
______________________________________________________________
BC8. Submit information demonstrating your Technology’s compliance with the technical
specifications of the Block Certification.
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:
______________________________________________________________
______________________________________________________________
______________________________________________________________
BC9. Submit information demonstrating your Technology’s compliance with the terms
and conditions of the referenced Block Certification.
BC10. Submit any other information concerning the Technology which may be helpful to
the Department in consideration of this application.

DHS Form 10004 (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 10004 (10/06)

County of: __________________________

________________________________________

Instructions for Completing Block Certification Application
Form:
Application Type
Item BC1. Type of Application
If your application is in response to an announced Block Certification, check the
appropriate box and follow the instructions set forth in the particular Block
Certification announcement.

Registration Information
Item BC2. Registration Information
Please check the appropriate box relating to your registration status.

Item BC3. Name of Seller
Please provide the legal name of the Seller/Applicant.

Item BC4. Company Description
The purpose of this item 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.
Provide a brief description of your company. When describing your company, focus
on identifying any affiliates associated with your Technology (e.g., parent companies,
subsidiaries, joint venture partners, holding companies, etc.).
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.

Block Certification
Item BC5. Seller
In certain instances, multiple corporate entities may appropriately be identified as a
Seller of the subject Technology. For instance, the Seller of the QATT could include a
parent company as well as subsidiaries or other affiliates. Your response will be used to
properly identify the Seller(s) of the QATT. If you would like multiple entities to be
considered a Seller of the QATT, please clearly identify these firms and identify their
respective place of incorporation.
DHS Form 10004 (10/06)

Item BC6. Earliest Date of Sale
This information will be used to specify the Earliest Date of Sale of the QATT to
which the Certification shall apply (note this date may be prior to the effective date of
the Certification).

Item BC7. Identification of Block Certification
Please identify the Block Certification to which you are responding by noting the name
of the Block Certification and the date it was issued. Reference any special terms or
conditions presented in the referenced Block Certification.
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 BC8. Compliance with Technical Merits
In order for the Under Secretary to extend SAFETY Act protections to your
Technology, please provide sufficient information to demonstrate that your
Technology complies with the technical merits of the reference Block Certification.
Please be specific.
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 BC9. Compliance with Terms and Conditions
Please demonstrate how your Technology complies with the terms and conditions
stated in the referenced Block Certification. Please be specific and provide sufficient
details.

Item BC10. Other Information
Please provide other information that may help the Department of Homeland Security
as it considers your application. This may include information such as material
demonstrating the Technology’s effectiveness, utility, and readiness for sale.

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 or number. Examples of
common attachments might include, but are not limited to, the following: test reports
demonstrating the effectiveness of the Technology, operating manuals, training
manuals, project/program management plans, quality assurance plans, quality control
plans, copies of test reports demonstrating effectiveness, results from pilot studies,
testimonials from customers, and warranties.
DHS Form 10004 (10/06)

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 10004 (10/06)