DSP-6 Application for Amendment To A DSP-5 License

OMB APPROVAL

EXPIRATION DATE: mm-dd-yy

*ESTIMATED BURDEN: 30 minutes

*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/RPS/DIR) Washington, DC 20520.

U. S. DEPARTMENT OF STATE

APPLICATION FOR AMENDMENT TO A DSP-5 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	Included Documents
DSP-6 Copy of DoS License with PM/DDTC Proviso(s)
Open Document	Open Document

Optional Documents

22 CFR § 126.13 Eligibility Letter

DTCC Acknowledgement Letter

Other Amplifying Data

Other DSP-6 Authorizations

Purchase order submitted with original license

Open Document

DSP-6

Revised Date

DSP-6, Page 1 or #

SEAL

Amendment Control No.

(text box – auto assigned)

Signature

The License identified in Block 4 below is amended as requested on the date indicated at the right of this form.

The Indicated License is Amended Effective on:

(text box – auto assigned)

UNITED STATES OF AMERICA DEPARTMENT OF STATE APPLICATION FOR AMENDMENT TO A DSP-5 LICENSE

*1. Date Prepared (text box – auto filled)

*2. PM/DDTC Applicant/Registrant Code

(text box)

3. Applicant Name, Address, ZIP Code and Telephone Number

*4. Amendment to License No

(text box)

I certify that the stated license has an unshipped balance and has not expired.

(Check box) Subsidiary

Add Subsidiary Information button

*5. Amendment in accordance with (select one)

*Name (text box)

22 CFR § 123.25

22 CFR § 122.4

6. Compliance Case Number

*Attention (text box)

*Address (text box)

a. Provide Compliance Case Number (text box, 10 characters)

*City (text box)

b. Provide date of DTCC Acknowledgement Letter (mm/dd/yyyy)

(text box)

*State (pick list)

*ZIP Code (text box)

*Telephone # (text box)

Ext (text box)

7. Name and Telephone Number of applicant contact(s) familiar

with the application and proposed amendments if U.S. Government

*8. Summary of Amendment(s) to DSP-5

needs additional information

Name (text box)

Type of Amendment(s) - a multiple pick list

Telephone # (text box)

Ext (text box)

Add button

9. Change Original PM/DDTC Applicant/Registrant Code (DSP-5 license, Block 2)

a. State specific reason for the change (text box) 500 chars

b. PM/DDTC Applicant/Registrant Code as stated on DSP-5 license

c. New PM/DDTC Applicant/Registrant Code

(text box) 1 letter from {‘ F’,’B’, ‘M’, ‘G’} and 5 chars

(text box) 1 letter from {‘ F’,’B’, ‘M’, ‘G’} and 5 chars

10. Change Original Applicant/Subsidiary (DSP-5 license, Block 5)

Item # 1:

a. Type of modification (select one)

Change in name of original applicant

Add subsidiary

Change in name of original subsidiary

Change in address, city, state and/or ZIP code of original applicant

Delete subsidiary

Change in address, city, state and/or ZIP code of original subsidiary

Change in name, address, city, state and/or ZIP code of original applicant

Change in name, address, city, state and/or ZIP code of original subsidiary

b. State specific reason for the change (text box) 500 chars

c. Applicant/Subsidiary as stated on original DSP-5 license

d. Modified Applicant/Subsidiary

Name (text box)

Name (text box)

Address (text box)

Address (text box)

City (text box)

City (text box)

State (pick list)

ZIP Code (text box)

State (pick list)

ZIP Code (text box)

Add button

DSP-6, Page 2 or #

11. Correction to Commodity Description (DSP-5 license, Block 10)

Item # 1:

a. Type of correction (select at least one)

Change part number

Correct typo

If changing a part number, (appears only if change part number is selected)

I certify that the change in the part number does not enhance, upgrade or change the capability of the commodity authorized for export.

b. State specific reason for the change (text box) 500 chars

c. Change From – Commodity description to include the part number as stated on original DSP-5 license

d. Corrected Commodity description to include the part number

Line item # (text box)

Line item # (auto filled)

Description (text box) 500 char

Description (text box) 500 char

Add button

12. Correction to Quantity (DSP-5 license, Block 9) and/or $ Value (DSP-5 license, Block 12)

Item # 1:

a. Type of correction (select at least one)

Correct Quantity

Correct $ Value

b. State specific reason for the change (text box) 500 chars

c. Change From – Quantity and/or $ Value as stated on original DSP-5 license

d. Change to – Quantity and/or $ Value as it should appear

Line Item #

Quantity

$ Value

Line Item #

Quantity

$ Value

Unit Price

Line Item Total

Unit Price

Line Item Total

(text box)

(text box)

(text box)

(text box)

(auto Filled)

(text box)

(text box)

(text box)

Unit Type

Unit Type

(Pick List)

(Pick List)

Add button

13. Revised DSP-5 License Total (DSP-5 license, Block 13):

a. Enter total $ value as stated on original DSP-5 license in Block 13

(text box)

b. Revised total $ value

(Calculated from Block 13a and changes in Block 12, or input)

14. Correction to Foreign End-User (DSP-5 license, Block 14)

Item # 1:

a. Correct typo

b. Foreign End-User as stated on original DSP-5 license

c. New Foreign End-User

Name (text box, 126 characters max )

Name (text box, 126 characters max )

Address (text box, 84 characters max )

Address (text box, 84 characters max )

City (text box, 42 characters max )

City (text box, 42 characters max )

Add Button

15. Change in Manufacturer of Commodity (DSP-5 License, Block 15)

Item # 1:

a. Type of Modification (select one)	Change in name of original manufacturer
Add new manufacturer	Change in address, city, state, and/or ZIP code of original manufacturer
Delete manufacturer	Change in name, address, city, state, and/or ZIP code of original manufacturer

If adding new manufacturer of commodity, (appears only if adding new manufacturer)

I certify that the addition of the new manufacturer does not enhance, upgrade or change the capability of commodity (ies) authorized for export.

b. State specific reason for the change

c. Manufacturer of Commodity as stated on original DSP-5 license					d. New/Modified Manufacturer of Commodity
Name					Name
Address					Address
City					City
State (pick list)			ZIP Code		State (pick list)			ZIP Code
Country	(pick list)				Country	(pick list)

Add More Items

DSP-6, Page 3 or #

16. Change in Source of Commodity (DSP-5 license, Block 17)
Item # 1:
a. Type of modification (select one)
Add new source		Change in name of original source
Delete source		Change in address, city, state and/or ZIP code of original source
Change in name, address, city, state and/or ZIP code of original source
If adding new source of commodity (appears only if adding new source), I certify that the addition of the new source does not enhance, upgrade or change the capability of commodity (ies) authorized for export.
b. State specific reason for the change
c. Source of Commodity as stated on original DSP-5 license					d. New/Modified Source of Commodity
Name (text box)					Name (text box)
Address (text box)					Address (text box)
City (text box)					City (text box)
State (pick list)	ZIP Code (text box)				State (pick list)	ZIP Code (text box)
Country (pick list)					Country (pick list)
Add button
17. Change Name, Address and/or City of Original Foreign Consignee (DSP-5 license, Block 16)
Item # 1:
Type of modification (select at least one) I certify that the change is not the result of a merger or acquisition.			Change in name of original foreign consignee
			Change in address and/or city of original foreign consignee
b. State specific reason for the change (select at least one)
Name Change Location 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.
Yes No Not Applicable
d. Foreign Consignee as stated on original DSP-5 license					e. Modified Foreign Consignee
Name (text box)					Name (text box)
Address (text box)					Address (text box)
City (text box)					City (text box)
Country (pick list)					Country (pick list from left)
Add button

DSP-6, Page 4 or #

18. Change Name, Address, City, State and/or ZIP Code of Original U.S. Seller (DSP-5 license, Block 19)
Item # 1:
a. Type of modification (select at least one)			Change in name of original U.S. seller
			Change in address, city, state and/or ZIP code of original U.S. seller
b. State specific reason for the change (text box) 500 chars
c. U.S. Seller as stated on original DSP-5 license					d. Modified U.S. Seller
Name (text box)					Name (text box)
Address (text box)					Address (text box)
City (text box)					City (text box)
State (pick list)		ZIP Code (text box)			State (pick list)		ZIP Code (text box)
Add button
19. Change in Foreign Intermediate Consignee (DSP-5, license Block 18)
Item # 1:
a. Type of modification (select one)
	Add new foreign freight forwarder			Change in name of original foreign intermediate consignee to include foreign freight forwarder
				Change in address and/or city of original foreign intermediate consignee to include foreign freight forwarder
				Change in name, address, city, and/or country of original foreign intermediate consignee to include foreign freight forwarder
b. State specific reason for the change (text box) 500 chars
c. Foreign Intermediate Consignee as stated on original DSP-5					d. New Foreign Intermediate Consignee
Name (text box)					Name (text box)
Address (text box)					Address (text box)
City (text box)					City (text box)
Country (pick list)					Country (if Add ,pick; otherwise auto filled from left row/column)
Add button
20. Change in U.S. Consignor and/or U.S. Freight Forwarder (DSP-5 license, Block 21)
Item # 1:
a. Type of modification (select one)
	Add new U.S. consignor/freight forwarder			Change in name of original U.S. consignor/freight forwarder
				Change in address, city, state and/or ZIP code of original U.S. consignor/freight forwarder
				Change in name, address, city, state and/or ZIP code of original U.S. consignor/freight forwarder
b. State specific reason for the change (text box) 500 chars
c. U.S. Consignor and/or U.S. Freight Forwarder as stated on original DSP-5 license					d. New/Modified U.S. Consignor or U.S. Freight Forwarder
Name (text box)					Name (text box)
Address (text box)					Address (text box)
City (text box)					City (text box)
State (pick list)		ZIP Code (text box)			State (pick list)		ZIP Code (text box)
Add button

DSP-6, Page 5 or #

21. Additional Details of Transaction
(text box) – 1000 chars
*22. Applicant’s Statement
I, ___________________________, an empowered official (22 CFR § 120.25) or an official 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 (select one)
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 in Block 21.
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 in Block 21. A request for an exception to policy is attached.
I am not authorized by the applicant to certify the conditions of 22 CFR § 126.13 as listed in Block 21. The applicant and all the parties to the transaction can meet in full the conditions of 22 CFR § 126.13 as listed in Block 21. Please see attached letter for such certification.
I am not authorized by the applicant to certify the conditions of 22 CFR § 126.13 as listed in Block 21. 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 in Block 21. A letter of such certification and request for an exception to policy is attached.
Signature				Signature button
23. Response to be sent to: (Enter name address and phone number:)
[Block is inactive on electronic form]
Name (text box)
Attention (text box)
Address (text box)
City (text box)
State (pick list)			ZIP Code (text box)
Telephone # (text box)			Ext. (text box)

DSP-6, Page 6 or #

CONDITIONS OF ISSUANCE

1. When approved, all of the original conditions except as modified by the Directorate of Defense Trade Controls (PM/DDTC) 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.

Subsidiary Information under Block 3, Page 1 of the DSP-6

Name
Attention
Address
City

State		ZIP Code
Telephone #		Ext

9

Edited Version of DSP 6

Rev 1.10 2 August 2005