Webform OMB 1124 0005 Change Request 2019

OMB No. 1124-0005; Expires May 31, 2020

Short Form Registration Statement
Pursuant to the Foreign Agents Registration Act of
1938, as amended

U.S. Department of Justice
Washington, DC 20530

INSTRUCTIONS. Each partner, officer, director, associate, employee, and agent of a registrant is required to file a short form registration statement
unless he engages in no activities in furtherance of the interests of the registrant's foreign principal or unless the services he renders to the registrant
are in a secretarial, clerical, or in a related or similar capacity. Compliance is accomplished by filing an electronic short form registration statement
at https://www.fara.gov.
Privacy Act Statement. The filing of this document is required for the Foreign Agents Registration Act of 1938, as amended, 22 U.S.C. § 611 et seq.,
for the purposes of registration under the Act and public disclosure. Provision of the information requested is mandatory, and failure to provide the
information is subject to the penalty and enforcement provisions established in Section 8 of the Act. Every registration statement, short form
registration statement, supplemental statement, exhibit, amendment, copy of informational materials or other document or information filed with the
Attorney General under this Act is a public record open to public examination, inspection and copying during the posted business hours of the
Registration Unit in Washington, DC. Statements are also available online at the Registration Unit’s webpage: https://www.fara.gov. One copy of
every such document, other than informational materials, is automatically provided to the Secretary of State pursuant to Section 6(b) of the Act, and
copies of any and all documents are routinely made available to other agencies, departments and Congress pursuant to Section 6(c) of the Act. The
Attorney General also transmits a semi-annual report to Congress on the administration of the Act which lists the names of all agents registered under
the Act and the foreign principals they represent. This report is available to the public and online at: https://www.fara.gov.
Public Reporting Burden. Public reporting burden for this collection of information is estimated to average .23 hours per response, including the
time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the
collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions
for reducing this burden to Chief, Registration Unit, Counterintelligence and Export Control Section, National Security Division, U.S. Department of
Justice, Washington, DC 20530; and to the Office of Information and Regulatory Affairs, Office of Management and Budget, Washington, DC 20503.

1. Name

2. Registration Number

3. Residence Address(es)

4. Business Address(es)

5. Year of Birth

6. If present citizenship was not acquired by birth,
indicate when, and how acquired.

Nationality
Present Citizenship
7. Occupation
8. What is the name and address of the primary registrant?
Name

Address

9. (a) Indicate your connection with the primary registrant:
partner
director
officer
associate
other (specify)_______________________________

□
□
□

□
□

□
□

employee
agent

□
□

consultant
subcontractor

(b) Specific Position/Title
10. List the foreign principal to whom you will render services in support of the primary registrant.

FORM NSD-6
Revised 06/19

11. Describe in detail all services which you will render to the foreign principal listed in Item 10 either directly, or
through the primary registrant listed in Item 8.

12. Do any of the above described services include political activity as defined in Section 1(o) of the Act1?
Yes
No

□

□

If yes, describe separately and in detail such political activity. The response must include, but not be limited to, activities
involving lobbying, promotion, perception management, public relations, economic development, and preparation or
dissemination of informational materials.

13. The services described in Items 11 and 12 are to be rendered on a

□ full time basis

□ part time basis

□ special basis

14. What compensation or thing of value have you received to date or will you receive for the above services?

□ Salary: Amount $ ___________ per ___________
□ Commission at _________ % of _______________
□ Salary: Not based solely on services rendered to the foreign principal(s).
□ Fee: Amount $ ___________
□ Other thing of value _________________________

15. During the period beginning 60 days prior to the date of your obligation to register to the time of filing this statement, did you
make any contributions of money or other things of value from your own funds or possessions and on your own behalf in
connection with any election to political office or in connection with any primary election, convention, or caucus held to select
No
candidates for any political office?
Yes

□

□

If yes, furnish the following information:
Date

Method

Political Organization or Candidate

Amount or Thing of Value

EXECUTION
In accordance with 28 U.S.C. § 1746, the undersigned swears or affirms under penalty of perjury that he/she has read the
information set forth in this registration statement and that he/she is familiar with the contents thereof and that such contents are in
their entirety true and accurate to the best of his/her knowledge and belief.
Sign

Date

Printed Name

Signature

1 "Political activity," as defined in Section 1(o) of the Act, means any activity which the person engaging in believes will, or that the person intends to, in any way influence
any agency or official of the Government of the United States or any section of the public within the United States with reference to formulating, adopting, or changing the
domestic or foreign policies of the United States or with reference to the political or public interests, policies, or relations of a government of a foreign country or a foreign
political party.