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pdfOMB APPROVAL NO. 1405-0204
EXPIRES: XX/XX/20XX
ESTIMATED BURDEN: 90 Minutes*
U.S. Department of State
RISK ANALYSIS INFORMATION
PART 1: INFORMATION ABOUT CONTRACT/GRANT/COOPERATIVE AGREEMENT
Name of Prospective Contractor/Grantee
Type (Contract, Grant, Other):
Contract
US Dollar Value of Contract/Grant (All Years) Contract/Grant Start Date (mm-dd-yyyy)
Grant
Other
Contract/Grant End Date (mm-dd-yyyy) Solicitation Number
Purpose of Contract/Grant
Address of Prospective Contractor/Grantee
Phone Number
Cell Phone Number
E-mail Address
PART 2: AFGHANISTAN
Please provide the following information if proposed contract or grant work will be in Afghanistan.
Afghanistan Business License Number
Joint Contingency Contracting System (JCCS) Number
PART 3: CERTIFICATION
I certify that I have taken reasonable steps (in accordance with sound business practices) to verify the information contained in this form. I understand
that the U.S. Government may rely on the accuracy of such information in processing this request.
Authorizing Official's Name (Last, First, MI)
Signature
DS-4184
08-2022
Title/Organization
Date (mm-dd-yyyy)
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KEY INDIVIDUAL INFORMATION #1
Name (Last, First, MI)
Other Names Used ("Also known as", nicknames, alias, different spelling)
Place of Birth (City, State, Province, Country)
Date of Birth (mm-dd-yyyy)
Gender:
Male
Citizenship(s)
U.S. citizen or Permanent Legal Resident?
Yes
Female
No
If yes, provide your U.S. Passport or Social Security Number
National ID Type
National ID Number
Home Address
Current Employer
Current Employer Phone
Organizational Title
Project Title
Country of Issuance
Home Phone
Cell Phone Number
Social Media Handles/Identifiers
E-mail Address
Current Employer Address
Afghan Citizen Use Only (If Section 2 Has Been Completed)
Father's Name
Tribe
Tazkera Number
Passport Number
Country of Issuance
KEY INDIVIDUAL INFORMATION #2
Name (Last, First, MI)
Other Names Used ("Also known as", nicknames, alias, different spelling)
Place of Birth (City, State, Province, Country)
Date of Birth (mm-dd-yyyy)
Gender:
Male
Citizenship(s)
U.S. citizen or Permanent Legal Resident?
Yes
Female
No
If yes, provide your U.S. Passport or Social Security Number
National ID Type
National ID Number
Home Address
Current Employer
Current Employer Phone
Organizational Title
Project Title
Country of Issuance
Home Phone
Cell Phone Number
Social Media Handles/Identifiers
E-mail Address
Current Employer Address
Afghan Citizen Use Only (If Section 2 Has Been Completed)
Father's Name
Tazkera Number
DS-4184
Tribe
Passport Number
Country of Issuance
Page 2 of 3
PAPERWORK REDUCTION ACT STATEMENT
*Public reporting burden for this collection of information is estimated to average 90 minutes 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 current 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: U.S. Dept. of State, 2201 C St. NW, SA-15 room 3200,
Washington, DC 20520.
PRIVACY ACT STATEMENT
Authority: 18 U.S.C. 2339A, 2339B, 2339C; 22 U.S.C. 2151 et seq.; Section 219 of the Immigration and Nationality Act (INA) (P.L. 104-132) (8
U.S.C. 1189); Executive Orders 13224, 13099 and 12947; Homeland Security Presidential Directive 6; Section 7034(f) of the Department of State,
Foreign Operations, and Related Programs Appropriations Act, 2022 (Div. K, P.L. 117-103) and similar provisions in prior appropriations acts.
Purpose: The information in the system supports the vetting of directors, officers, or other employees of organizations who apply for Department of
State contracts, grants, or other funding. The information collected from the organizations and individuals is specifically used to conduct screening to
ensure that Department funds are not used to provide support to entities or individuals deemed to be a risk to US national security interests.
Routine Uses: The information is used to make determinations on applications for contracts, grants or other funding and may be disclosed to the
United States Agency for International Development (USAID) and other government agencies for collaborative vetting programs. For additional details
on Routine Uses not listed here, refer to the Department of State's System of Record Notice concerning the Risk Analysis and Management System
(RAM) (State 78).
Disclosure: Providing the information is voluntary. Failure to provide the information will result in a finding of ineligibility for Department funding.
INSTRUCTIONS
Appendix Key Individuals or Recipients (Use continuation sheets, as necessary)
Key individuals may include but are not limited to:
The organization/company's President, Vice President, Executive Director, Deputy Executive Director, Chief Executive Officer, Chief Operating
Officer, Treasurer, Secretary, and the Board of Directors.
It may also include Program Managers or Project Managers.
Recipients may include but are not limited to:
Individual who may benefit from or participate in a U.S.-funded program, for example, as an attendee at a U.S. government-sponsored training
session.
Proposed Subcontractors or Sub-grantees must also complete a separate Information Form listing their key personnel.
Indicate "N/A" if a category does not apply. If no organization or company is listed, complete the information on each individual who will receive
cash or in-kind assistance (including technical assistance).
DS-4184
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| File Type | application/pdf |
| File Title | DS-4184 |
| Author | A/GIS/DIR |
| File Modified | 2022-11-01 |
| File Created | 2022-11-01 |