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OMB APPROVAL NO. 1405-0092
EXPIRATION DATE: 05-31-2018
*ESTIMATED BURDEN: 30 MINUTES
9.3
* PAPERWORK REDUCTION ACT STATEMENT: Public reporting burden for this collection of information is estimated to average 30 minutes 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/ISS/DIR) Washington, D.C. 20520.
U.S. DEPARTMENT OF STATE
APPLICATION FOR AMENDMENT TO A DSP-61 LICENSE
*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 application. Classified information must be sent
separately to PM/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
DSP-62
Copy of DoS License with PM/DDTC Proviso(s)
Optional Documents
22 CFR § 126.13 Certification Letter
22 CFR § 127.11 Exception to Policy Letter
DTCC Acknowledgement Letter
Other Amplifying Data
Other DSP-62 Authorizations
Purchase order submitted with original license
DSP-62
Included Documents
DSP-62, Page 1
SEAL
Amendment Control No.
Signature
The Indicated License is
Amended Effective on:
The License identified in Block 4 below is amended as requested on the date indicated
at the right of this form.
DEPARTMENT OF STATE
UNITED STATES OF AMERICA
APPLICATION FOR AMENDMENT TO A DSP-61 LICENSE
*1. Date Prepared
*2. DDTC Registration Code
02/15/2018
3. Applicant
*4. Amendment to License #
Subsidiary
I certify that the stated license has an unshipped balance and
has not expired.
*Name
*5. Amendment in accordance with
22 CFR 123.25
*Attention
22 CFR 122.4
6. Compliance Case Number
*Address
a. Compliance Case Number
*City
*ZIP Code
*State
Ext
*Telephone #
b. Date of DTCC Acknowledgement Letter (mm/dd/yyyy)
7. Applicant Contact for Additional Information
Name
Telephone #
Ext
Add
*8. Summary of Amendment(s) to DSP-61
9. Change in DDTC Registration Code (DSP-61 Block 2)
a. State specific reason for the change:
b. PM/DDTC Applicant/Registrant Code as stated on DSP-61 license:
c. New DDTC Registration Code:
10. Change in Applicant/Subsidiary (DSP-61 Block 8)
Item #1:
a. Type of Modification (select one):
b. State specific reason for the change:
c. Applicant/Subsidiary as stated on original DSP-61 license:
d. Modified Applicant/Subsidiary:
Name
Name
Attention
Attention
Address
Address
City
City
State
ZIP Code
Add
State
ZIP Code
of
6
DSP-62, Page 2
of
6
11. Change in Commodity Description (DSP-61 Block 12)
Item # 1:
a. Type of Modification (select at least one):
Change part number
Correct typographical error
b. State specific reason for the change:
c. Change From - Commodity description to include the part number as
stated on original DSP-61:
d. Corrected Commodity description to include the part number:
Line Item #
Line Item #
Description
Description
Add
12. Change in Quantity (DSP-61 Block 11) and/or $ Value (DSP-61 Block 14)
Item # 1:
a. Type of Modification (select at least one):
Correct Quantity
Correct Value
b. State specific reason for the change:
c. Change From - Quantity and/or $ Value as stated on original DSP-61
license:
Item #
Quantity
$ Value
Unit Price
d. Change to - Quantity and/or $ Value as it should appear:
Item #
Line Item Total
Unit Type
Quantity
$ Value
Unit Price
Line Item Total
Unit Type
Add
13. Change in DSP-61 License Total (DSP-61 Block 15)
a. Enter total $ value as stated on original DSP-61 license in Block 15:
b. Revised total $ value
14. Change in Owner/End-User of Commodity in Foreign Country from which Shipped (DSP-61 Block 16)
Item # 1:
a. Type of Modification (select at least one):
Change in name of original foreign end-user
Change in address and/or city of original foreign end-user
b. State specific reason for the change:
c. For any change where the license is in furtherance of an agreement, the applicant has completed the amendment to the agreement required by 22
CFR 124 to reflect this change. (select one):
Yes
No
Not Applicable
d. Owner/End-User of Commodity in Foreign Country from which
Shipped as stated on original DSP-61 license:
e. Modified Owner/End-User of Commodity in Foreign Country from
which Shipped:
Name
Name
Address
Address
City
City
Country
Country
Add
DSP-62, Page 3
of
6
15. Change in Manufacturer of Commodity (DSP-61 Block 17)
Item # 1:
a. Type of Modification (select one):
b. State specific reason for the change:
c. Manufacturer of Commodity as stated on original DSP-61 license:
d. New/Modified Manufacturer of Commodity:
Name
Name
Address
Address
City
City
State
ZIP Code
Country
State
ZIP Code
Country
Add
16. Change in Source of Commodity (DSP-61 Block 19)
Item # 1:
a. Type of Modification (select one):
b. State specific reason for the change:
c. Source of Commodity as stated on original DSP-61 license:
d. New/Modified Source of Commodity:
Name
Name
Address
Address
City
City
State
ZIP Code
Country
State
ZIP Code
Country
Add
17. Change in Consignor in Foreign Country from which Shipped (DSP-61 Block 18)
Item # 1:
a. Type of Modification (select at least one):
Change in name of original foreign consignor
Change in address and/or city of original foreign consignor
b. State specific reason for the change:
c. For any change where the license is in furtherance of an agreement, the applicant has completed the amendment to the agreement required by 22 CFR
124 to reflect this change. (select one):
Yes
No
Not Applicable
d. Consignor in Foreign Country from which Shipped as stated on
original DSP-61 license:
e. Modified Consignor in Foreign Country from which Shipped:
Name
Name
Address
Address
City
City
Country
Add
Country
DSP-62, Page 4
of
6
18. Change in Foreign Intermediate Consignee (DSP-61 Block 20)
Item # 1:
a. Type of Modification (select one):
b. State specific reason for the change:
c. Foreign Intermediate Consignee as stated on original DSP-61 license:
d. New Foreign Intermediate Consignee:
Name
Name
Address
Address
City
City
Country
Country
Add
19. Change in U.S. Intermediate Consignee (DSP-61 Block 21)
Item # 1:
a. Type of Modification (select one):
b. State specific reason for the change:
c. For any change where the license is in furtherance of an agreement, the applicant has completed the amendment to the agreement required by 22 CFR
124 to reflect this change. (select one):
Yes
No
Not Applicable
d. U.S. Intermediate Consignee as stated on original DSP-61 license:
e. New/Modified U.S. Intermediate Consignee:
Name
Name
Address
Address
City
City
State
ZIP Code
State
ZIP Code
Add
20. Change in Consignee in Foreign Country of Ultimate Destination (DSP-61 Block 22)
Item # 1:
a. Type of Modification (select at least one):
Change in name of original consignee in foreign country of ultimate destination
Change in address and/or city of original consignee in foreign country of ultimate destination
b. State specific reason for the change:
c. For any change where the license is in furtherance of an agreement, the applicant has completed the amendment to the agreement required by 22 CFR
124 to reflect this change. (select one):
Yes
No
Not Applicable
d. Consignee in Foreign Country of Ultimate Destination as stated on
original DSP-61 license:
e. Modified Consignee in Foreign Country of Ultimate Destination:
Name
Name
Address
Address
City
City
Country
Add
Country
DSP-62, Page 5
of
6
21. Change in Owner/End-User in Foreign Country of Ultimate Destination (DSP-61 Block 24)
Same as Block 14
Item # 1:
a. Type of Modification (select at least one):
Change in name of original owner/end-user in foreign country of ultimate destination
Change in address and/or city of original owner/end-user in foreign country of ultimate destination
b. State specific reason for the change:
c. Owner/End-User in Foreign Country of Ultimate Destination as stated on
original DSP-61 license:
d. Modified Owner/End-User in Foreign Country of Ultimate Destination:
Name
Name
Address
Address
City
City
Country
Country
Add
22. Additional Details of Transaction
* This application is related to a disclosure filed with Defense Trade Controls Compliance
No
Yes
Enter Compliance Disclosure Number:
Category
*USML Category
*23. Applicant's Statement
, an empowered official (22 CFR 120.25) or an official
I,
of a foreign government entity in the U.S., hereby apply for approval of the above amendment(s); warrant the truth of all statements made herein; and
acknowledge, understand and will comply with the provisions of 22 CFR 120-130, and any conditions and limitations imposed.
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 CFR 120.27 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 22 CFR 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
license or other approval from any agency of the U.S. Government.
*22 CFR 126.13 Certification
a. 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 above.
b. 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 above. A request for an exception to policy, as described in 22 CFR 127.11 of the ITAR, is attached.
c. 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 above. However that party has met the conditions imposed by the Directorate of Defense Trade Controls in
order to resume standard submission of applications, not requiring an exception to policy as described in 22 CFR 127.11 of the ITAR.
d. I am not authorized by the applicant to certify the conditions of 22 CFR 126.13. The applicant and all of the parties to the transaction can meet in full
the conditions of 22 CFR 126.13 as listed above. Please see the attached letter from an official that is authorized by the applicant to certify to the
conditions of 22 CFR 126.13.
e. I am not authorized by the applicant to certify the conditions of 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 above. A request for an exception to policy, as described in 22 CFR 127.11 of the ITAR, and a
letter from an official that is authorized by the applicant to certify to the conditions of 22 CFR 126.13 are attached.
f. I am not authorized by the applicant to certify the conditions of 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 above. However that party has met the conditions imposed by the Directorate of Defense Trade
Controls in order to resume standard submission of applications, not requiring an exception to policy as described in 22 CFR 127.11 of the ITAR.
Please see the attached letter from an official that is authorized by the applicant to certify to the conditions of 22 CFR 126.13.
Signature
Signature
24. Response to be sent to: (Enter Name, Address and phone number)
[Block is inactive on electronic form]
Name
Attention
Address
City
State
Telephone #
ZIP Code
Ext
DSP-62, Page 6
of
CONDITIONS OF ISSUANCE
1. When approved, all of the original conditions and limitations except as modified by the Directorate of Defense Trade Controls remain applicable.
2. This amendment, when approved, becomes a part of the license identified in Block 4 on Page 1 of this form. When returned to the applicant, it must
be attached to the original license prior to further use of the license or must be provided to U.S. Customs and Border Protection for filing
with the original license.
DISPOSITION OF AMENDMENT
The final disposition of this amendment shall be in accordance with 22 CFR 123.22(c) and be accomplished with the final disposition of the license
identified in Block 4 on Page 1.
6
DSP-62, Page
Subsidary Information under Block 3, Page 1 of the DSP-62
*Name
*Attention
*Address
*City
*State
*Telephone #
*ZIP Code
Ext
of
6
Complete List of Amendments under Block 8, Page 1 of the DSP-62
Total Number of Amendments Selected : 0
DSP-62, Page 6
of
6
Additional Applicant/Subsidiary Changes
1
of
DSP-62, Page 6
1
Change Original Applicant/Subsidiary (DSP-61 Block 8)
10. Change in Applicant/Subsidiary (DSP-61 Block 8)
Item #2:
a. Type of Modification (select one):
b. State specific reason for the change:
c. Applicant/Subsidiary as stated on original DSP-61 license:
d. Modified Applicant/Subsidiary:
Name
Name
Attention
Attention
Address
Address
City
City
State
ZIP Code
State
ZIP Code
10. Change in Applicant/Subsidiary (DSP-61 Block 8)
Item #3:
a. Type of Modification (select one):
b. State specific reason for the change:
c. Applicant/Subsidiary as stated on original DSP-61 license:
d. Modified Applicant/Subsidiary:
Name
Name
Attention
Attention
Address
Address
City
City
State
ZIP Code
State
ZIP Code
of
6
| File Type | application/pdf |
| File Title | Submission |
| Author | BattistaAL |
| File Modified | 2018-02-15 |
| File Created | 2018-02-15 |