INVOICE-AND-CONTRACT ABSTRACT

<table>
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<tbody>
<tr class="odd">
<td colspan="6" rowspan="2"><p>1. COMMODITY SUPPLIER’S NAME AND
ADDRESS</p>
<p>     </p></td>
<td colspan="4"><p>2. FOR USAID USE</p>
<p>     </p></td>
</tr>
<tr class="even">
<td colspan="4"><p>3. USAID IMPLEMENTATION NUMBER</p>
<p>     </p></td>
</tr>
<tr class="odd">
<td colspan="10"><p>4. IMPORTER’S NAME AND ADDRESS</p>
<p>     </p></td>
</tr>
<tr class="even">
<td colspan="3"><p>5. VESSEL</p>
<p>     </p></td>
<td colspan="3"><p>6. FLAG</p>
<p>     </p></td>
<td colspan="4"><p>7. PORT OF LOADING</p>
<p>     </p></td>
</tr>
<tr class="odd">
<td colspan="10">8. COMMODITY INFORMATION</td>
</tr>
<tr class="even">
<td colspan="5">a. Description of commodity and Schedule B No.</td>
<td colspan="3">b.Gross Weight</td>
<td colspan="2">c. Measurement</td>
</tr>
<tr class="odd">
<td colspan="5">     </td>
<td colspan="3">     </td>
<td colspan="2">     </td>
</tr>
<tr class="even">
<td colspan="2">9. INVOICE INFORMATION</td>
<td colspan="3">10. CONTRACT INFORMATION</td>
<td colspan="5">11. SUPPLIER INFORMATION</td>
</tr>
<tr class="odd">
<td colspan="2"><p>a. Number</p>
<p>     </p></td>
<td colspan="3"><p>a. Number</p>
<p>     </p></td>
<td colspan="3"><p>a. U.S. Small Business</p>
<p> Yes No (Complete b)</p></td>
<td colspan="2"><p>b. Estimated Value (% of block 9c) Furnished From
U.S. Small Businesses</p>
<p>      %</p></td>
</tr>
<tr class="even">
<td colspan="2"><p>b. Date</p>
<p>     </p></td>
<td colspan="3"><p>b. Date</p>
<p>     </p></td>
<td colspan="3" rowspan="2"><p>c. U.S. Small Disadvantaged</p>
<p>Business</p>
<p> Yes No (Complete d)</p></td>
<td colspan="2" rowspan="2"><p>d. Estimated Value (% of block 9c)
Furnished From U.S. Small Disadvantaged Businesses</p>
<p>      %</p></td>
</tr>
<tr class="odd">
<td colspan="2"><p>c. Amount After Discount</p>
<p>     </p></td>
<td colspan="3"><p>c. Total Amount</p>
<p>     </p></td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td colspan="3"><p>d. Source/Origin (Country)</p>
<p>     </p></td>
<td colspan="3"><p>e. U.S. Women-Owned Small Business</p>
<p> Yes No (Complete f)</p></td>
<td colspan="2"><p>f. Estimated Value (% of Block 9c) Furnished From
U.S. Women-Owned Small Business</p>
<p>      %</p></td>
</tr>
<tr class="odd">
<td colspan="5" rowspan="2"></td>
<td colspan="3"><p>g. U.S. Veteran-Owned Small Business</p>
<p> Yes No (Complete h)</p></td>
<td colspan="2"><p>h. Estimated Value (% of Block 9c) Furnished From
U.S. Veteran-Owned Small Business</p>
<p>      %</p></td>
</tr>
<tr class="even">
<td colspan="3"><p>i. U.S. Service-Disabled Veteran-Owned Small
Business</p>
<p> Yes No (Complete j)</p></td>
<td colspan="2"><p>j. Estimated Value (% of Block 9c) Furnished From
U.S. Service-Disabled Veteran-Owned Small Business</p>
<p>      %</p></td>
</tr>
<tr class="odd">
<td colspan="5">12. INSURANCE INFORMATION</td>
<td colspan="5">13. TRANSPORTATION INFORMATION</td>
</tr>
<tr class="even">
<td><p>a. Insured Value</p>
<p>     </p></td>
<td colspan="4" rowspan="3"><p>c.</p>
<p> All-Risk Rate      </p>
<p> War Risk Rate      </p>
<p> Other (Specify)</p>
<p>      Rate      </p></td>
<td colspan="4"><p>a. Vessel Type</p>
<p> Bulk Liner Tanker Air</p></td>
<td><p>d. Freight Rate</p>
<p>     </p></td>
</tr>
<tr class="odd">
<td><p>b. Premium</p>
<p>b. Premium</p></td>
<td colspan="4"><p>b. B/L or Air Waybill Number</p>
<p>     </p></td>
<td><p>Other Freight Charges</p>
<p>     </p></td>
</tr>
<tr class="even">
<td>     </td>
<td colspan="4"><p>c. B/L or Air Waybill Date</p>
<p>     </p></td>
<td><p>Total Freight Charges</p>
<p>     </p></td>
</tr>
<tr class="odd">
<td colspan="10">14. INFORMATION AS TO COMMISSIONS, CREDITS, ALLOWANCES,
SIMILAR PAYMENTS, AND SIDE PAYMENTS</td>
</tr>
<tr class="even">
<td colspan="4"><p>a. Recipient’s Name</p>
<p>     </p></td>
<td colspan="5"><p>b. Recipient’s Address</p>
<p>     </p></td>
<td><p>c. Amount Paid or To Be Paid</p>
<p>     </p></td>
</tr>
<tr class="odd">
<td colspan="7"><p><strong>15. ADDITIONAL INFORMATION AND
REMARKS</strong></p>
<p><strong>     </strong></p>
<p><strong>Note to Paying Offices: Forward one(1) copy of the form
submission to OSDBU/MRC, USAID/W</strong></p></td>
<td colspan="3"><p>16. If Certification On Other Side Is Made By</p>
<blockquote>
<p> Carrier Or Insurer, Type Or Print</p>
<p>Name And Address Of Company.</p>
</blockquote>
<p>     </p></td>
</tr>
</tbody>
</table>

**SUPPLIER'S CERTIFICATE AND AGREEMENT WITH**

**THE U.S. AGENCY FOR INTERNATIONAL DEVELOPMENT**

+-----------------------------------+-----------------------------------+
| The supplier hereby acknowledges  | 9\. If the supplier is the        |
| that the sum claimed on the       | producer, manufacturer, or        |
| accompanying invoice to be due    | processor of the commodity, said  |
| and owing under the terms of the  | contract is not a                 |
| purchase contract identified on   | cost-plus-percentage-of-cost      |
| the reverse hereof ('said         | contract.                         |
| contract') is to be paid, in      |                                   |
| whole or in part, out of funds    | 10\. The supplier will for a      |
| made available by the U.S. Agency | period of not less than three (3) |
| for International Development     | years after the date hereof       |
| (USAID) under the Foreign         | maintain all business records and |
| Assistance Act of 1961, as        | other documents which bear on its |
| amended. In consideration of the  | compliance with any of the        |
| receipt of such sum, the supplier | undertakings and certifications   |
| agrees with and certifies to      | herein and will, at any time      |
| USAID as follows:                 | requested by USAID, promptly make |
|                                   | such records and documents        |
| 1\. The undersigned is the        | available to USAID for            |
| supplier of the commodities or    | examination and promptly furnish  |
| commodity-related services        | to USAID additional information   |
| indicated in the                  | in such form as USAID may request |
| Invoice-and-Contract Abstract on  | concerning the purchase price,    |
| the reverse hereof, has complied  | the cost to the supplier of the   |
| with the applicable provisions of | commodities and/or                |
| Regulation 1 (22 CFR Part 201),   | commodity-related services        |
| as in effect on the date hereof   | involved, and/or any other facts, |
| is entitled under said contract   | data, or business records         |
| and under the applicable letter   | relating to the supplier's        |
| of credit, credit advice, or      | compliance with its undertakings  |
| other payment instructions to     | and certifications in this        |
| payment of the sum claimed, and   | certificate and agreement.        |
| is executing this Certificate and |                                   |
| Agreement to obtain such payment  | 11\. The supplier has complied    |
| from USAID funds.                 | with the provisions contained and |
|                                   | referred to in subpart D of USAID |
| 2\. On the basis of information   | Regulation 1.                     |
| from such sources as are          |                                   |
| available to the supplier upon    | 12\. The supplier was not         |
| reasonable investigation and to   | ineligible to act as a supplier   |
| the best of its information and   | or otherwise participate in the   |
| belief, the purchase price is not | USAID financed transactions at    |
| higher than the maximum price     | the time of approval of the USAID |
| permitted under each of the       | Commodity Approval Application.   |
| applicable price rules of subpart |                                   |
| G of USAID Regulation 1.          | 13\. The commodity supplier       |
|                                   | certifies that it has submitted a |
| 3\. The supplier will, upon       | copy of every ocean bill of       |
| request of USAID, promptly refund | lading, applicable to the         |
| to USAID any amount by which the  | commodities and transactions      |
| purchase price exceeds the        | described on the reverse hereof   |
| maximum price permitted under     | to: (i) the Maritime              |
| such provisions of subpart G of   | Administration, National Cargo    |
| Regulation 1, plus interest \[at  | Division, 400 Seventh Street,     |
| rate established in accordance    | S.W., Washington, D.C.            |
| with the Internal Revenue Code,   | 20590-0001; and (ii) Office of    |
| 26 U.S.C. 6621 (a)(2)\] from the  | Acquisition and Assistance,       |
| time of payment to the supplier.  | Transportation and Commodity      |
|                                   | Division, USAID, Washington, D.C. |
| 4\. The supplier will, upon       | 20523-7900 and that such bill(s)  |
| request of USAID, promptly make   | of lading state all the carrier's |
| appropriate refund to USAID, plus | charges including the basis for   |
| interest from the time of payment | calculation, such as weight or    |
| to the supplier, in the event of  | cubic measurements.               |
|                                   |                                   |
| (a) its nonperformance, in whole  | 14\. The supplier has filled in   |
|     or in part, under said        | all applicable portions of the    |
|     contract, or including any    | Invoice-and-Contract Abstract on  |
|     failure to pay dispatch or    | the reverse hereof and certifies  |
|                                   | to the completeness and           |
| (b) any breach by it of any of    | correctness of the information    |
|     its undertakings in this      | shown therein.                    |
|     Certificate and Agreement, or |                                   |
|                                   | PERSONAL CERTIFICATION BY NATURAL |
| (c) any false certificate or      | PERSON SIGNING THIS CERTIFICATE   |
|     representation made by it in  | AND AGREEMENT                     |
|     this Certificate and          |                                   |
|     Agreement or in the           | The natural person who signs this |
|     Invoice-and-Contract Abstract | Certificate and Agreement hereby  |
|     on the reverse hereof.        | certifies either that he/she is   |
|                                   | the supplier or that he/she has   |
| 5\. The amount shown on the       | actual authority to sign on       |
| reverse hereof in block 9c is net | behalf of the supplier and to     |
| of all trade discounts, whether   | bind the supplier with regard to  |
| in the form of payments, credits, | all certifications and agreements |
| or allowances by the supplier or  | contained in this Certificate and |
| its agent to or for the account   | Agreement. He/she further         |
| of the importer, including        | certifies, if he/she is not       |
| quantity and prompt payment       | personally the supplier, that     |
| discounts allowed other customers | he/she is either an employee of   |
| under similar circumstances. The  | the supplier or has a written     |
| supplier will promptly pay to     | power of attorney to sign for and |
| USAID any adjustment refunds,     | bind the supplier. He/she         |
| credits, or allowances which      | acknowledges signing and          |
| hereafter become payable to or    | submitting this Certificate and   |
| for the account of the importer   | Agreement to receive payment from |
| arising out of the terms of said  | USAID funds and that USAID in     |
| contract or the customs of the    | making such payment will rely on  |
| trade in compliance with          | the truth and accuracy of this    |
| instructions received from USAID. | Personal Certificate as well as   |
|                                   | all other representations in this |
| 6\. The supplier has complied     | Certificate and Agreement.        |
| with the provisions of Section    |                                   |
| 201.65 of USAID Regulation 1 and  | The Supplier's Certificate and    |
| has not compensated any person to | Agreement and the Personal        |
| obtain said contract except to    | Certificate herein shall be       |
| the extent, if any, indicated on  | governed by and interpreted       |
| the reverse hereof.               | according to the laws of the      |
|                                   | United States of America.         |
| 7\. The supplier or its agent has |                                   |
| not given or received and will    | Type or print name and title of   |
| not give or receive a side        | official authorized to sign       |
| payment, "kickback," commission,  |                                   |
| or any other payment, credit,     | Signature of official authorized  |
| allowance or benefit of any kind  | to sign for (check one) Date      |
| in connection with the said       |                                   |
| contract or any transaction or    | Commodity Supplier Carrier        |
| series of transactions of which   | Insurer                           |
| said contract is a part, other    |                                   |
| than those payments or benefits   | Place executed (City, County,     |
| permitted under Section 201.65 of | State, Country)                   |
| USAID Regulation 1 and those      |                                   |
| referred to in paragraphs 1 and 5 | NOTES: (a) Any amendments of or   |
| above.                            | additions to the printed          |
|                                   | provisions of this Supplier's     |
| 8\. Any commodity supplied under  | Certificate and Agreement are     |
| said contract                     | improper and will not be          |
|                                   | considered a part hereof. (b)     |
| (a) is accurately described on    | False statements herein are       |
|     the reverse hereof and,       | punishable by United States Law.  |
|     unless otherwise authorized   | (c) The word "Copy" must be       |
|     by USAID, is new and unused,  | written after the signature on    |
|     is not rebuilt or             | all copies other than the         |
|     reconditioned, does not       | original.                         |
|     contain any rebuilt or        |                                   |
|     reconditioned components, and |                                   |
|     has not been disposed of as   |                                   |
|     surplus by any government     |                                   |
|     agency; and                   |                                   |
|                                   |                                   |
| (b) on the basis of information   |                                   |
|     from such sources as are      |                                   |
|     available to the supplier     |                                   |
|     upon reasonable               |                                   |
|     investigation, and to the     |                                   |
|     best of its information and   |                                   |
|     belief, meets the             |                                   |
|     requirements of Section       |                                   |
|     201.11(b) of USAID Regulation |                                   |
|     1 as to source, origin and    |                                   |
|     nationality, and limitation   |                                   |
|     on components.                |                                   |
+-----------------------------------+-----------------------------------+

**INSTRUCTIONS FOR COMPLETING FORM AID 282**

+-----------------------------------+-----------------------------------+
| PAPERWORK REDUCTION ACT NOTICE.   | INSTRUCTIONS FOR INDIVIDUAL       |
| Information furnished will be     | BLOCKS                            |
| used to verify compliance with    |                                   |
| legal requirements, as a basis    | Block 1: Enter the commodity      |
| for recourse in the event of      | supplier's name and address       |
| noncompliance, and to monitor     |                                   |
| participation in USAID programs.  | BLOCK 2: For USAID use *only*.    |
| It will be disclosed outside      |                                   |
| USAID only as provided by law.    | BLOCK 3: Enter USAID implementing |
| Submission of this information    | document number furnished in the  |
| has been determined to be         | Letter of Credit or Importer's    |
| necessary to receive payment from | instructions. This number will    |
| USAID funds pursuant to 22 U.S.C. | normally be the Letter of         |
| 2381.                             | Commitment number.                |
|                                   |                                   |
| Public reporting burden for this  | BLOCK 4: ENTER THE IMPORTER'S     |
| collection of information is      | NAME AND ADDRESS.                 |
| estimated to average thirty       |                                   |
| minutes per response, including   | Caution: on documents prepared    |
| the time for reviewing            | from the Standard Master, such as |
| instructions, searching existing  | the Bill of Lading, the           |
| data sources, gathering and       | corresponding block may call for  |
| maintaining the data needed, and  | the name and address of the party |
| completing and reviewing the      | to whom the carrier is to give    |
| collection of information. You    | notice of arrival. When such      |
| are not required to provide       | party is not the importer; be     |
| information requested on the a    | sure to enter the importer's name |
| form subject to the Paperwork     | and address.                      |
| Reduction Act unless the form     |                                   |
| displays a valid OMB control      | BLOCK 5: Enter the name of the    |
| number (see OMB control number in | vessel or airline.                |
| upper right-hand corner of page   |                                   |
| 1). Send comments regarding this  | BLOCK 6: Enter the flag of        |
| burden estimate or any other      | registry of vessel or airplane.   |
| aspect of this collection of      |                                   |
| information, including            | BLOCK 7: Enter the port shown on  |
| suggestions for reducing this     | the Bill of Lading.               |
| burden to:                        |                                   |
|                                   | BLOCK 8: COMMODITY INFORMATION    |
| > U.S. Agency for International   |                                   |
| > Development                     | a.  Enter the description of each |
| >                                 |     commodity and its U.S.        |
| > Office of Acquisition and       |     Department of Commerce        |
| > Assistance                      |     Schedule B number, if         |
| >                                 |     available. For multi-item     |
| > Policy Division (M/OAA/P)       |     invoices, enter a summary     |
| >                                 |     description of the group of   |
| > Washington, D.C. 20523-7801     |     items and the appropriate     |
| >                                 |     Schedule B number (s), if     |
| > and                             |     available.                    |
| >                                 |                                   |
| > Office of Management and Budget | b.  Enter the Bill of Lading/Air  |
| >                                 |     Way bill weight.              |
| > Paperwork Reduction Project     |                                   |
| > (0412-0012)                     | c.  Enter the Bill of Lading/Air  |
| >                                 |     Way bill measurement.         |
| > Washington, D.C. 20503          |                                   |
|                                   | BLOCK 9: INVOICE INFORMATION      |
| Do NOT use the above addresses    |                                   |
| for submitting the form.          | a.  Enter the number of the       |
|                                   |     accompanying invoice to which |
| EXECUTION AND SUBMISSION OF FORM. |     this abstract relates.        |
| This form is designed for use     |                                   |
| with the U.S. Standard Master for | b.  Enter the invoice date.       |
| International Trade. An original  |                                   |
| and one (1) copy of this form,    | c.  Enter the net amount for      |
| completed by the following        |     which the supplier seeks      |
| suppliers, as applicable, must    |     payment *(see paragraphs 5    |
| accompany each invoice for which  |     and 6 of the Supplier's       |
| payment is requested:             |     Certificate).*                |
|                                   |                                   |
| (a) Commodity Supplier --         | BLOCK 10: CONTRACT INFORMATION    |
|     executed by the commodity     |                                   |
|     supplier covering the cost of | a.  Enter the contract number.    |
|     the commodity, including the  |                                   |
|     cost of any commodity --      | b.  Enter the date of the         |
|     related service paid by the   |     contract.                     |
|     commodity supplier for its    |                                   |
|     own or the buyer's account;   | c.  Enter the total contract      |
|                                   |     amount.                       |
| (b) Transportation Supplier       |                                   |
|     (Carrier) -- executed by each | d.  Enter the country of source   |
|     carrier or in the case of a   |     as defined in Section 201.01  |
|     through Bill of Lading, the   |     of USAID Regulation 1.        |
|     issuing carrier, for the cost |                                   |
|     of the ocean or air           | BLOCK 11: SUPPLIER INFORMATION    |
|     transportation financed by    |                                   |
|     USAID, whether or not the     | Complete only when a U.S. address |
|     transportation is paid by the | is indicated in Block 1. The      |
|     commodity supplier;           | information is required to enable |
|                                   | USAID to compile reports          |
| (c) Insurance Supplier (Insurer)  | requested by Congress.            |
|     -- executed by the insurer    |                                   |
|     (or under the circumstances   | a\. Indicate whether the supplier |
|     set forth in Section          | is U.S. small business. "U.S.     |
|     201.52(b)(2) of USAID         | small business" means a concern,  |
|     Regulation 1, by an insurance | including its affiliates, that    |
|     broker or the commodity       | is: (i) located in the United     |
|     supplier), whether or not the | States and making a significant   |
|     insurance is paid by the      | contribution to the U.S. economy  |
|     commodity supplier, for the   | (through payment of taxes and/or  |
|     cost of marine insurance      | use of American products,         |
|     financed by USAID when such   | material and/or labor), (ii)      |
|     cost exceeds \$50.            | organized for profit, (iii)       |
|                                   | independently owned and operated, |
| The original *must* be signed by  | (iv) not dominant in the field of |
| a person authorized by the        | operation in which it has bid on  |
| supplier who shall indicate       | the subject contract, and (v)     |
| his/her title and certify to      | qualified as a small business     |
| his/her authority.                | under the criteria and size       |
|                                   | standards in 13 C.F.R. part 121.  |
| SUBMISSION IN ENGLISH LANGUAGE.   | The size standards are available  |
| The form must be completed in the | on the Internet at                |
| English language *only* and all   | http://www.sba.gov/size.          |
| amounts of money must be shown in |                                   |
| U.S. dollars.                     | For size standard purposes, a     |
|                                   | product or service shall be       |
| OBTAINING FORMS. The form (as     | classified in only one industry,  |
| well copies of USAID Regulation 1 | whose definition best describes   |
| referenced in this form) may be   | the principal nature of the       |
| obtained in limited quantities    | product or service being acquired |
| from banks holding USAID Letters  | even though for other purposes it |
| of Commitment, from district      | could be classified in more than  |
| offices of the Department of      | one. When a contract covers the   |
| Commerce, the USAID office in the | purchase of multiple products or  |
| supplier's country, or the        | services that could be classified |
| Information and Records Division  | in two or more industries with    |
| (M/AS/IRD), U.S. Agency for       | different size standards, apply   |
| International Development,        | the size standard for the         |
| Washington, D.C. 20523-2701.The   | industry accounting for the       |
| form is also available as a macro | greatest percentage of the        |
| on USAID's website at             | contract price.                   |
| http://[www.usa                   |                                   |
| id](http://www.usaid/).gov/forms. | b\. If the supplier is not a U.S. |
| The form may be reproduced,       | small business, enter the best    |
| providing the reproduction is     | estimate of the percentage of the |
| identical in size and format.     | total invoice amount paid or to   |
|                                   | be paid to subcontractors or      |
| INSTRUCTIONS FOR COMPLETING       | suppliers of components who are   |
| ENTRIES ON INVOICE-AND-CONTRACT   | U.S. small businesses.            |
| ABSTRACT                          |                                   |
|                                   | c\. Indicate whether the supplier |
| GENERAL INSTRUCTIONS              | is a U.S. small disadvantaged     |
|                                   | business. "Small disadvantaged    |
| Except as provided in the         | business" means a business (i)    |
| instructions for specific blocks, | which is at least 51 percent      |
| suppliers must complete all       | owned by one or more socially and |
| blocks or enter the letters 'NA'  | economically disadvantaged        |
| (Not Applicable), as follows:     | individuals or, in the case of a  |
|                                   | publicly owned business, at least |
| Commodity Supplier -- Complete    | 51 percent of the stock of which  |
| all Blocks except 12 and 13;      | is owned by one or more socially  |
| however, if the commodity         | disadvantaged individuals, and    |
| supplier has paid for the         | (ii) whose management and daily   |
| transportation and/or insurance   | business operations are           |
| for its own or the buyer's        | controlled by one or more such    |
| account, Blocks 12 and/or 13 will | individuals.                      |
| also be completed by the          |                                   |
| commodity supplier; Block 11 is   | "Socially disadvantaged"          |
| to be completed only when the     | individuals are those who have    |
| address in block 1 is a U.S.      | been subjected to racial or       |
| address.                          | ethnic prejudice or cultural bias |
|                                   | because of their identity as a    |
| Transportation Supplier (Carrier) | member of a group without regard  |
| -- Complete Blocks 1 through 8 as | to their qualities as             |
| well as 13, 14, and 16.           | individuals.                      |
|                                   |                                   |
| Insurance Supplier (Insurer) --   |                                   |
| Complete Blocks 1 through 8a as   |                                   |
| well as 12, 14, and 16.           |                                   |
+-----------------------------------+-----------------------------------+

**INSTRUCTIONS FOR COMPLETING FORM AID 282 (cont.)**

+-----------------------------------+-----------------------------------+
| "Economically disadvantaged       | BLOCK 12: INSURANCE INFORMATION   |
| individuals" means socially       |                                   |
| disadvantaged individuals whose   | COMPLETE BLOCK 12 *only* if the   |
| ability to compete in the free    | insurance premium exceeds \$50.   |
| enterprise system is impaired due |                                   |
| to diminished opportunities to    | a.  Enter the insured value of    |
| obtain capital and credit as      |     the shipment.                 |
| compared to others in the same    |                                   |
| line of business who are not      | b.  Enter the total premium.      |
| socially disadvantaged. Provided  |                                   |
| that their individuals net worth  | c.  Enter the type of coverage    |
| does not exceed \$750,000 (after  |     and insurance rate. If        |
| taking into account exclusions    |     "Other" is checked, explain   |
| set forth in 13 C.F.R. 124, 104   |     in Block 15.                  |
| (c)(9)), individuals, who certify |                                   |
| that they are members of named    | BLOCK 13: TRANSPORTATION          |
| groups (Black Americans, Hispanic | INFORMATION                       |
| Americans, Native Americans,      |                                   |
| Asian-Pacific Americans,          | a.  Check vessel type.            |
| Subcontinent-Asian Americans) are |                                   |
| rebuttably to be presumed         | b.  Enter Bill of Lading or air   |
| socially and economically         |     waybill number.               |
| disadvantaged.                    |                                   |
|                                   | c.  Enter Bill of Lading or air   |
| "Subcontinent Asian Americans"    |     waybill date.                 |
| means United States citizens      |                                   |
| whose origins are in India,       | d.  Enter the freight rate, other |
| Pakistan, Bangladesh, Sri Lanka,  |     freight charges and the total |
| Bhutan, Nepal, or the Maldives.   |     dollar amount of freight      |
|                                   |     charges after discount.       |
| "Asian Pacific Americans" means   |                                   |
| United States citizens whose      | BLOCK 14: INFORMATION AS TO       |
| origins are in Japan, China, the  | COMMISSIONS, CREDIT, ALLOWANCES,  |
| Philippines, Vietnam, Korea,      | SIMILAR PAYMENTS AND SIDE         |
| Samoa, Guam, the U.S. Trust       | PAYMENTS                          |
| Territory of the Pacific Islands  |                                   |
| (Republic of Palau), the Northern | Enter information on (a) all      |
| Mariana Islands, Laos, Cambodia,  | commissions and other payments,   |
| Taiwan, Burma, Thailand,          | credits, allowances or benefits   |
| Malaysia, Indonesia, Singapore,   | or any kind, paid or to be paid   |
| Brunei, Republic of the Marshall  | by the supplier to or for the     |
| Islands, the Federated States of  | benefit of its agent, the         |
| Micronesia, or Commonwealth of    | importer, or the importer's agent |
| the Northern Mariana Islands.     | as required by Section 201.65 of  |
|                                   | USAID Regulation 1; and (b) any   |
| "Native Americans" means American | side payments, not shown on the   |
| Indians, Eskimos, Aleuts, and     | invoice, made or to be made by    |
| native Hawaiians.                 | the importer to the supplier, in  |
|                                   | connection with the transaction,  |
| d\. If the supplier is not a      | as required by Section 201.66 of  |
| small disadvantaged business,     | USAID Regulation 1. If there is   |
| enter the best estimate of the    | insufficient space to furnish the |
| percentage of the total invoice   | required information in block 14, |
| amount paid or to be paid to      | continue in block 15 or enter     |
| subcontractors or suppliers of    | "Continued" or "See attached" in  |
| components who are socially and   | block 14a, and attach a separate  |
| economically disadvantaged        | sheet to the form. If no          |
| enterprises.                      | commissions or other payments,    |
|                                   | credits, allowances, benefits, or |
| e\. Indicate whether the supplier | side payments are involved, enter |
| is a U.S. women-owned small       | "NONE" in block 14.               |
| business. "Women-owned small      |                                   |
| business" means a business which  | BLOCK 16: If the Supplier's       |
| is at least 51 percent owned by   | Certificate is completed by the   |
| one or more women who are United  | carrier or insurer, check the     |
| States citizens and who also      | appropriate box and print or type |
| control and operate the business. | carrier's or insurer's name and   |
|                                   | address.                          |
| f\. If the supplier is not a U.S. |                                   |
| women-owned small business, enter |                                   |
| the best estimate of the          |                                   |
| percentage of the total invoice   |                                   |
| amount paid or to be paid to      |                                   |
| subcontractors or suppliers of    |                                   |
| components who are women-owned    |                                   |
| business.                         |                                   |
|                                   |                                   |
| g\. Indicate whether the supplier |                                   |
| is a U.S. veteran-owned small     |                                   |
| business. "U.S. veteran-owned     |                                   |
| small business" means a U.S.      |                                   |
| small business that (i) not less  |                                   |
| than 51 percent of which is owned |                                   |
| by one or more U.S. military      |                                   |
| veterans (as defined at 38 U.S.C. |                                   |
| 101(2)) or, in the case of any    |                                   |
| publicly-owned business, not less |                                   |
| than 51 percent of the stock of   |                                   |
| which is owned by one or more     |                                   |
| veterans, and (ii) the management |                                   |
| and daily business operations of  |                                   |
| which are controlled by one or    |                                   |
| more veterans.                    |                                   |
|                                   |                                   |
| h\. If the supplier is not a U.S. |                                   |
| veteran-owned small business,     |                                   |
| enter the best estimate of the    |                                   |
| percentage of the total invoice   |                                   |
| amount paid or to be paid to      |                                   |
| subcontractors or suppliers or    |                                   |
| components that are U.S.          |                                   |
| veteran-owned small businesses.   |                                   |
|                                   |                                   |
| i\. Indicate whether the supplier |                                   |
| is a U.S. service-disabled        |                                   |
| veteran-owned small business.     |                                   |
| "Service-disabled veteran-owned   |                                   |
| small business means:             |                                   |
|                                   |                                   |
| 1\. A small business (i) not less |                                   |
| than 51 percent of which is owned |                                   |
| by one or more service-disabled   |                                   |
| veterans, or in the case of any   |                                   |
| publicly-owned business, not less |                                   |
| than 51 percent of the stock of   |                                   |
| which is owned by one or more     |                                   |
| service-disabled veterans, and    |                                   |
| (ii) the management and daily     |                                   |
| business operations of which      |                                   |
| controlled by one or more         |                                   |
| service-disabled veterans, or in  |                                   |
| the case of a service-disabled    |                                   |
| veteran with permanent and severe |                                   |
| disability, the spouse or         |                                   |
| permanent caregiver of such       |                                   |
| veteran.                          |                                   |
|                                   |                                   |
| 2\. "Service-disabled veteran"    |                                   |
| means a veteran, with a           |                                   |
| disability that is                |                                   |
| service-connected, as defined in  |                                   |
| 38 U.S.C. 101(16).                |                                   |
|                                   |                                   |
| j\. If the supplier is not a U.S. |                                   |
| service-disabled veteran-owned    |                                   |
| small business, enter the best    |                                   |
| estimate of the percentage of the |                                   |
| total invoice amount to be paid   |                                   |
| to subcontractors or suppliers of |                                   |
| components who are U.S.           |                                   |
| service-disabled veteran-owned    |                                   |
| small businesses.                 |                                   |
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| DO NOT INCLUDE THE INSTRUCTIONS ON PAGE 3 AND 4                       |
|                                                                       |
| WITH THE SUBMISSION OF THE COMPLETED FORM.                            |
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