CFIUS Real Estate Declaration Submission Form for Real Estate Transactions

U.S. DEPARTMENT OF THE TREASURY

Declaration Submission Form for Real Estate Transactions Under 31 C.F.R. Part 802

IMPORTANT: All fields on this form are required unless otherwise explicitly noted.

1. List all parties, including the foreign person(s) and the current holder(s) of interest in the real estate that are parties to, or in applicable cases, the subject of, the transaction, as well as the name, telephone number, and email address of the primary point of contact for each party:

Current Holder of Interest in Real Estate Foreign Person(s)

Name: Name:

Point of Contact: Point of Contact:

Telephone: Telephone:

Primary email: Primary email:

Secondary contact email (optional): Secondary contact email (optional):

2. Are all parties to this transaction submitting this declaration jointly? ⃝ Yes ⃝ No

3. For the transaction, provide:

a. A brief description of the rationale for and nature of the transaction, including its structure (e.g., purchase, lease, or concession):

b. Total transaction value in U.S. dollars:

c. Actual or expected completion date of the transaction:

d. All sources of financing for the transaction and any real estate agents or brokers involved:

4. Attach here a copy of the definitive documentation of the transaction, or if none exists, the document establishing the material terms of the transaction.

5. For the real estate that is the subject of the transaction, provide:

a. The location, by address and geographic coordinates in decimal degrees to the fourth digit:

b. The name(s) of the relevant airport, maritime port, military installation, or any other facility or property of the U.S. Government as defined in 31 C.F.R. part 802, based on the location of the real estate:

6. Describe the real estate that is the subject to the transaction including:

a. The approximate size (in acres, feet, or other appropriate measurement):

b. The nature of the real estate (e.g., zoning type and major topographical or other features of the real estate):

c. The current use of the real estate; plans with respect to the real estate; and structures that are or will be on the real estate:

7. Describe of any licenses, permits, easements, encumbrances, or other grants or approvals associated with the real estate that is the subject of the transaction:

8. Will the transaction afford the foreign person the right or ability to:

a. Physically access the real estate that is the subject of the transaction? ⃝ Yes ⃝ No

b. Exclude others from physical access to the real estate that is the subject of the transaction? ⃝ Yes ⃝ No

c. Improve or develop the real estate that is the subject of the transaction? ⃝ Yes ⃝ No

d. Attach fixed or immovable structures or objects to the real estate that is the subject of the transaction? ⃝ Yes ⃝ No

11. Provide the name of the ultimate parent of the foreign person:

12. Provide the principal place of business and address of the foreign person, the ultimate parent and ultimate owner of such parent:

13. Attach here a complete pre-transaction organizational chart (and post-transaction, if different) including, without limitation, information that identifies the name, principal place of business and place of incorporation or other legal organization (for entities), and nationality (for individuals), and ownership percentage (expressed in terms of both voting and economic interest, if different) for each of the following:

a. The immediate parent, the ultimate parent, and each intermediate parent, if any, of each foreign person that is a party to the transaction.

b. Where the ultimate parent is a private company, the ultimate owner(s) of such parent.

c. Where the ultimate parent is a public company, any shareholder with an interest of greater than five percent in such parent.

14. Provide information regarding all foreign government ownership in the foreign person’s ownership structure, including nationality and percentage of ownership, as well as any rights that a foreign government holds, directly or indirectly, with respect to the foreign person:

15. With respect to the foreign person that is party to the transaction and any of its parents, as applicable, a brief summary of their respective business activities:

16. Do the parties to the transaction stipulate that the transaction is a covered real estate transaction? ⃝ Yes ⃝ No

17. If applicable, describe the basis for the stipulation:

18. If any party to the transaction has been party to another transaction(s) previously notified or submitted to the Committee, provide the case number(s) assigned by the Committee regarding such transaction(s):

19. Provide a brief statement as to whether the holder of the real estate that is the subject of the transaction, the foreign person, or any parent or subsidiary of the foreign person has been convicted of a crime within the past ten years, including the relevant jurisdiction and criminal case law number or legal citation:

20. Attach here a certification from each party submitting the declaration that the information contained in the declaration is consistent with 31 C.F.R. 802.203.

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