DS-7787 Disclosure of Information Related to Potential Violation

OMB APPROVAL NO. 1405-0179
EXPIRA
IRAT
TIO
ION
N DAT
DATE: 04/30/2020
*ESTIMATED BURDEN: 10 HOURS
DISCLOSURE #:_______________
U.S. Department of State
DS-7787: Disclosure of Information to the Office of Defense Trade Controls Compliance

(SEE INSTRUCTIONS)
DO NOT INCLUDE CLASSIFIED INFORMATION ON THIS FORM
*PAPERWORK REDUCTION ACT STATEMENT: Public reporting burden for this collection of information is estimated to average 10 hours 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/GIS/DIR) Washington, D.C. 20520.

Block 1: Identifying Information
Registered with DDTC?

Yes

No

If “Registered with DDTC” is Yes

Add

Registration Code:
Organization Type Information:
Corporation

Partnership

Limited Liability Company

Sole Proprietorship

Individual

Educational Institution

Other. If Other, please specify:
Is this organization a Non-Profit?

Yes

Submitter Identifying Information:

Natural Person

No
Entity

If "Submitter Identifying Information" is Natural Person
First Name:
Middle Name:

None

Last Name:
,I6XEPLWWHU,GHQWLI\LQJ,QIRUPDWLRn" is Entity
Parent company should be listed here; applicable subsidiaries will be listed on page 2.
Company or Organization:
Doing Business as Name:
Address Line 1:
Address Line 2:
Address Line 3:
City:

Country:

State/Province:

ZIP/Postal Code:

Website:

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Does the submitter own, or otherwise control, any U.S. or foreign affiliates or subsidiaries that are involved in the disclosure of information
to DDTC?
Yes
No
If yes:
Company or Organization:
Doing Business as Name:
Address Line 1:
Address Line 2:
Address Line 3:
City:

Country:

State/Province:

ZIP/Postal Code:

Website:

U.S. Person:

Yes

Relationship:

Affiliate

No

Subsidiary

Add
Block 2. Point of Contact Information
Name:
Telephone:

Email:

Point of Contact Type:

Submitter

Third Party

Company or Organization:
Address Line 1:
Address Line 2:
Address Line 3:
City:

Country:

State/Province:

ZIP/Postal Code:

Website:

Add
Block 3. Disclosure Information
Submission Type:

Initial Voluntary Disclosure

Full Voluntary Disclosure

Supplemental Information

Response to DTCC Inquiry

Extension Request

Notification

Other

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If "Submission Type" is Full Voluntary Disclosure
Disclosure Case Number:
If "Submission Type" is Supplemental Information
Disclosure Case Number:
If "Submission Type" is Response to DTCC Inquiry
Disclosure Case Number:
If "Submission Type" is Extension Request
Disclosure Case Number:
Proposed Due Date:
Explanation:

If "Submission Type" Notification
Notification Type:
126.1 Notification

Third-Party Violation Notification

Other (specify):

Identify the entity or natural person that the Notification is concerning. Provide name and address:

If "Submission Type" Other
Disclosure Case Number:
Purpose of Submission:

Block 4.Violation Summary Information

DDTC encourages respondents to review the DS-7787 instructions for clarifications related to completing this section.
Violation Start Date:
Violation End Date:
Description of and Circumstances Surrounding Violation: (If providing a narrative, submitters should provide complete information by uploading a document
in Block 5 and choosing "Voluntary Disclosure Narrative" for Document Type.)

ITAR Section Violated:

Add

Defense Article (including Technical Data) and/or Defense Service Description:

USML Category:

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Significant Military Equipment Involved?

Yes

No

Classified Information Involved?

Yes

No

Please refer to DDTC's website, pmddtc.state.gov for instructions on how to properly submit
Classified Information.

Identify any relevant Department of State license or authorization:
Authorization Number:

Add

Exemption Citation:

Add

If "Exemption Citation" is Other
Other Exemption Citation:

Foreign Country/Foreign Person Nationality:

126.1 Country/National Involved?

Yes

Add
No

Identities and Addresses of Persons Involved:

Root Cause of Violation:

Corrective Actions:

Related to Previous Disclosures?

Yes

No

If "Related to Previous Disclosures" is Yes

Add

Disclosure Case Number:

Block 5. Disclosure or Relevant Documents
File Name:

Browse

Document Type:
Voluntary Disclosure Narrative

Technology Control Plan

Empowered Official/Senior Official Certification

Licensing/Authorization Document

Response to DTCC Inquiry

Shipping Document

Audit Report

Training Document

Compliance Program Manual, Policy, or Procedure

Notification Letter

Technical Data

Exhibit

Extension Request Letter

Other (specify):

Upload
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Block 6. Submission Authorization
I am an authorized employee of the company cited in Block 1, or an authorized third party as indicated in Block 2 to submit on behalf of the company in
Block 1. I certify to the accuracy and completeness of the submission, and have not knowingly omitted information.
Disclaimers/Notices
The provisions of ITAR Section 127.12 do not, nor should they be relied on to, create, confer, or grant any rights, benefits, privileges, or protection enforceable by law or in
equity by any person in any civil, criminal, administrative, or other matter.
Any relevant documents must be retained by the person making the disclosure until the Directorate of Defense Trade Controls requests them or until a final decision on the
disclosed information has been made.
NOTICE TO SUBMITTER: If this submission (including supporting documentation) contains proprietary, business-sensitive, or other commercial or financial information
about the submitter, its business, and/or its activities that would not customarily be made available to the general public, the Department of State recommends that the
submitter mark all documents in accordance with the guidelines located at 22 CFR 171.12. Submitters should also be aware of the provisions and limitations of the Freedom
of Information Act (5 U.S.C 552, as amended) when submitting information to the Directorate of Defense Trade Controls.
WARNING: False statements made knowingly or willfully to the federal government are punishable by fines and/or imprisonment under U.S. Law, including the provisions
of 18 U.S.C. 1001 and/or 18 U.S.C 1621.
Privacy Act Statement
AUTHORITIES: The information is sought pursuant to the Arms Export Control Act (AECA, 22 U.S.C. 2778), the International Traffic in Arms Regulations (ITAR, 22 CFR
120-130) and Executive Order 13637.
PURPOSE: The principal purpose of gathering this information is to allow the Directorate of Defense Trade Controls (DDTC) to determine whether to take administrative
action concerning any violation of the Arms Export Control Act that may have occurred. DDTC encourages the disclosure of information by persons who believe they may
have violated any provision of the AECA, ITAR, or any order, license, or other authorization issued under the AECA.
ROUTINE USES: The information supplied on this form may be made available to appropriate agencies for law enforcement or pursuant to a court order. It may also be
used to send required reports to Congress about certain defense transactions. More information on the Routine Uses for the system can be found in the System of Records
Notice State-42, Munitions Records.
DISCLOSURE: Disclosure of this information is voluntary unless pursuant to 22 CFR 123.17, 126.1, 126.16, 126.17. Failure to report a violation may result in
circumstances detrimental to the U.S. national security and foreign policy interests and will be an adverse factor in determining the appropriate disposition of such
violations.

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