Form DLA Form 1822 DLA Form 1822 End-Use Certificate

Clear
IFB/CONTRACT/OFFER/SF122/SF123 ORDER NO.

END-USE CERTIFICATE

FOR AGENCY USE ONLY

(STATEMENT REGARDING DISPOSITION AND USE OF PROPERTY)
(Please read Privacy Act Statement on reverse before completing this form.
If additional space is required, use separate sheets and identify by Block Number.)
TYPE OR PRINT ALL INFORMATION

TSC
CLD

PRIMARY
PURCHASER

SUB-PURCHASER
1

2

3

YES

4

Form Approved
OMB No. 0704-0382
Expires Jul 31, 2011

NO

The public reporting burden for this collection of information is estimated to average 20 minutes 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 DoD, Washington Headquarters Services, DIOR (0704-0382), 1215 Jefferson Davis Highway, Suite 1204, Arlington, VA
22202-4302. Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it
does not display a currently valid OMB control number. Please DO NOT RETURN your form to either of these addresses. RETURN COMPLETED FORM TO THE OFFICE STATED ON THE IFB,
SOLICITATION OR PROPOSAL.

INSTRUCTIONS. This form must be fully completed by all applicants for Munitions List Items (MLI)/Commerce Control List Items (CCLI) prior to acceptance by
the U.S. Government and constitutes an integral part of this bid. The information given must be true and correct and will become a part of this contract. Every
block MUST have an entry. If necessary, insert ''NONE, '' ''SAME AS BLOCK X ' or ''NOT APPLICABLE'' (do not use ''N/A ''). If the applicant is acting solely as an
Agent, a DLA Form 1822 must be signed by the Principal. The term Approving Official is used to indicate the person authorized to act for the U.S. Government
(Sales Contracting Officer Plant Clearance Officer or other designated individual). FOR ALL SALES OF PROPERTY APPROVED BY PLANT CLEARANCE
OFFICERS UPON THE REMOVAL OF THE PROPERTY, ALL DOCUMENTATION REQUIRED BY THIS FORM WILL BE FORWARDED TO THE IDENTIFIED TRADE
SECURITY CONTROL OFFICE.
The following applies to all property subject to sale using this form: the use, disposition, export, or re-export of this property, is subject to the publications,
penalties, and other provisions of the economic programs administered by the Office of Foreign Assets Control, U.S. Treasury Department, 31 CFR Chapter V.
THIS STATEMENT IS SUBMITTED IN CONNECTION WITH:
SALE

EXCHANGE

LINE ITEM NUMBER/COMMODITY

OTHER:

NAME (Last, First, Middle)

DATE OF BIRTH (MM/DD/YY)

SSN/ALIEN CARD NO./COUNTRY ID

PLACE OF BIRTH (City or County, State, Country)

TELEPHONE NUMBER (Include Area Code)

PHYSICAL ADDRESS

MAILING ADDRESS

SECTION I. GENERAL INFORMATION
APPLICABILITY. This statement applies to the property for which we have submitted our bid/offer pursuant to the above identified invitation.
SOLE PROPRIETORSHIP

PARTNERSHIP

2. NATURE OF END-USER'S BUSINESS

CORPORATION

OTHER (Specify):

3. NATURE OF PRINCIPAL'S BUSINESS

5. BUSINESS/CORPORATION HEADQUARTERS

6. BRANCH OFFICE

A. NAME

A. NAME

B. ADDRESS (Physical location)

B. ADDRESS (Physical location)

4. FIRM'S ID/FEDERAL TAX NUMBER

7. ALL CORPORATE OFFICERS, PARTNERS AND/OR AGENTS ARE TO PROVIDE, ON SEPARATE SHEETS OF PAPER, THEIR NAMES, ADDRESSES, SSNs, DATES
AND PLACES OF BIRTH. FAILURE TO PROVIDE THIS INFORMATION COULD RESULT IN SIGNIFICANT DELAY OR DENIAL OF THE AWARD.

SECTION II. END USE/USER INFORMATION. If this is a negotiated exchange, identify the property being exchanged:
1. PURPOSE. THE PROPERTY REFERRED TO IN ABOVE IFB/OFFER NUMBER WILL BE UTILIZED FOR THE FOLLOWING:
Enter and 'X' in the appropriate item(s) below. In the case of resale, Item 1.F. or 1.G. MUST be marked.
A. Retention for the following specific use
(see note):

D. The property may be exported or
re-exported in the form received to the
following country/countries:

B. Resold in the form received for the
following use (see note) :

C. The property will not be sold or otherwise
disposed of for use outside of the United States
or to non-U.S. Citizens/Nationals in the United
States.

E. Resale after following alteration (description

F. If sold, name, address, and telephone number
of sub-purchaser(s) :

of final production) :
in (Country/Countries) :
and distribution in (Country/Countries) :

G. The customers are unknown at this time. If required by the contract/transfer document, I will obtain prior written approval for the resale of any of the
property covered by this contract.
ADDITIONAL INFORMATION: State any other material facts relating to end user and use of the property which may be of value in considering the proposal:

NOTE: Example of specific uses: AIRCRAFT. The bidder/recipient certifies that the aircraft will be used: as a flyable aircraft; as a nonflyable aircraft to be used
only for parts, display, or ground instruction, etc.; for resale as a flyable aircraft.

DLA FORM 1822, JUL 2008

ALL OTHER VERSIONS ARE OBSOLETE

PAGE 1 OF 2

PDF (DLA)

SECTION Ill. UNDERSTANDING AND NOTIFICATIONS
1 . The use, disposition, export and re-export of this property is subject to all applicable U.S. Laws and Regulations, including
but not limited to the Arms Export Control Act (22 USC 2751 et seq.); Export Administration Act of 1979 (50 USC App.
2401 et seq.) as continued under Executive Order 12924; International Traffic in Arms Regulations (22 CFR 120 et seq.);
Export Administration Regulations (15 CFR 730 et seq.); Foreign Assets Control Regulations (31 CFR 500 et seq.) and the
Espionage Act (18 USC 793 et seq.); which, among other things, prohibit:
A. The making of false statements and concealment of any material information regarding the use or disposition, export or
re-export of the property and
B. Any use, disposition, export or re-export of the property not permitted by applicable statute and regulation.
2. The submission of false or misleading information and/or concealment of any material facts regarding the use, disposition
or export of this property may constitute a violation of provisions of 18 USC 793/1001, 22 USC 2778/2779, 50 USC App.
2410, and 50 USC App. 1-44. Sanctions for violations will be in conformity with U.S. laws and regulations (including
Federal Acquisition Regulations and DoDD 2030.8) and may include the denial of U.S. export privileges and of any
participation in future U.S. Government contracts.
3. Transfers of MLI and CCLI property by purchasers/bidders are subject to the requirements of the appropriate licensing
department or agency. In many cases, an export license or other authorization may be required. With respect to MLI,
registration of the purchaser's/bidder's business with the Department of the State may also be required. It is the responsibility
of the purchaser/bidder to determine what the applicable requirements may be and to obtain all necessary authorization or approvals.
4. When MLI/CCLI property is transferred, the information in this form regarding the above laws and regulations must be
passed to the subsequent purchaser/receiver. Records of Resale in buyer's possession should be available for Trade Security
Controls Office review, if requested.
5. The Invitation For Bid and Sale/Exchange Contract number can be referenced when submitting an application for an export
license or other authorization to the Department of State for MLI or Department of Commerce for CCLI.
6. The Government expects the Purchaser/Recipient to cooperate with all authorized Government representatives to verify
the existence and condition of MLI/CCLI.

SECTION IV. CERTIFICATION STATEMENT TO BE SIGNED BY BIDDER AT TIME OF RESPONSE TO IFB
1 . I do certify that all information given in this Statement Regarding Disposition and Use of Property is true and correct to the
best of my knowledge and belief and have not knowingly omitted any information which is inconsistent with this statement.
I understand this statement will be referred to and be a part of the contract of sale/exchange with the U.S. Government. I
agree to submit a written request for amendment of this statement to the Approving Official prior to effecting any change of
fact or intention from that stated herein or in any prior amendment, whether occurring before or after the release of the
commodities, and not to effect such changes without first receiving written approval of the Approving Official.
2. I acknowledge having been advised that the MLI/CCLI property I purchased is controlled by the U.S. Government and in
many cases cannot be transferred (exported, sold or given) to a foreign country, a non-U.S. Citizen/National or a
non-Permanent US Resident without a valid State/Commerce Department export authorization. Should I transfer this property
to a foreign country, a non-U.S. Citizen/National or a non-Permanent US Resident, I will obtain any required authorization
before making such transfers. I will not transfer this property to countries, regimes and nationals targeted under the sanctions
program administered by the U.S. Treasury Department's Office of Foreign Assets Control.
3. Neither the applicant, corporate officers, directors or partners 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 from any agency of the U.S. Government.
4. The person signing this DLA Form 1822 is:
a Citizen of the United States of America, or
lawfully admitted to the United States for Permanent Residence and maintains such residence under the
Immigration and Nationality Act, as amended (8 USC 1101 (a), 20, 60 Stat. 163) , or
a Citizen of
, and/or
is an official of a foreign government entity in the United States.
A. NAME (Type or print)

B. SIGNATURE

C. DATE SIGNED

PRIVACY ACT STATEMENT
AUTHORITY:
10 USC 136; 40 USC 471; 50 USC 2411; 22 USC 2751; and EO 9397.
PRINCIPAL PURPOSE(S): Determine applicant eligibility to participate in the program and ensure that property recipients comply with the
terms of the sale.
ROUTINE USES:
Data may be disclosed to the Departments of State, Commerce, Treasury, Transportation and Justice for determining
compliance with applicable laws and regulations and to the General Services Administration to determine presence of
debarment proceedings against a recipient.
DISCLOSURE:
Voluntary; however, failure to provide the requested information may result in ineligibility to receive surplus or foreign
personal property. DLA PRIVACY ACT SYSTEM NOTICE S800. 10 DLSC APPLIES - SEE THIS NOTICE FOR FURTHER
INFORMATION.
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DLA FORM 1822, JUL 2008 (BACK)
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ALL OTHER VERSIONS ARE OBSOLETE