+--------------------+---+-----+---+----------+---+---+-------+-----------+
| **DEPENDENT        |   |     |   |          |   |   |       |           |
| CERTIFICATION**    |   |     |   |          |   |   |       |           |
+--------------------+---+-----+---+----------+---+---+-------+-----------+
| 1\. Name of        |   |     |   |          |   |   | 2\.   |           |
| Participant *(Mr., |   |     |   |          |   |   | Stra  |           |
| Mrs., Ms.) (Last,  |   |     |   |          |   |   | tegic |           |
| First, Middle)*    |   |     |   |          |   |   | Obje  |           |
|                    |   |     |   |          |   |   | ctive |           |
|                    |   |     |   |          |   |   |       |           |
|                    |   |     |   |          |   |   |       |           |
+--------------------+---+-----+---+----------+---+---+-------+-----------+
| 3\. Activity Title |   |     |   |          |   |   | 4\.   |           |
|                    |   |     |   |          |   |   | P     |           |
|                    |   |     |   |          |   |   | rojec |           |
|                    |   |     |   |          |   |   | t/Act |           |
|                    |   |     |   |          |   |   | ivity |           |
|                    |   |     |   |          |   |   | N     |           |
|                    |   |     |   |          |   |   | umber |           |
|                    |   |     |   |          |   |   |       |           |
|                    |   |     |   |          |   |   |       |           |
+--------------------+---+-----+---+----------+---+---+-------+-----------+
| 5\. Type of        |   |     |   | 6\.      |   |   | 7\.   |           |
| Training           |   |     |   | Length   |   |   | Co    |           |
| *(Academic,        |   |     |   | of       |   |   | untry |           |
| In-Service, etc.)* |   |     |   | Training |   |   | of    |           |
|                    |   |     |   |          |   |   | Tra   |           |
|                    |   |     |   | *(Mos.)* |   |   | ining |           |
|                    |   |     |   |          |   |   |       |           |
|                    |   |     |   |          |   |   |       |           |
+--------------------+---+-----+---+----------+---+---+-------+-----------+
| 8\. I hereby       |   |     |   |          |   |   |       |           |
| request that USAID |   |     |   |          |   |   |       |           |
| grant permission   |   |     |   |          |   |   |       |           |
| for the following  |   |     |   |          |   |   |       |           |
| dependent members  |   |     |   |          |   |   |       |           |
| of my family to    |   |     |   |          |   |   |       |           |
| join me during my  |   |     |   |          |   |   |       |           |
| training program   |   |     |   |          |   |   |       |           |
| in       for an    |   |     |   |          |   |   |       |           |
| estimated length   |   |     |   |          |   |   |       |           |
| of    months.      |   |     |   |          |   |   |       |           |
+--------------------+---+-----+---+----------+---+---+-------+-----------+
| 9\. Full Name(s)   | D |     | P |          | N |   |       | Rel       |
| Of Dependents      | a |     | l |          | a |   |       | ationship |
|                    | t |     | a |          | t |   |       |           |
| *(Attach           | e |     | c |          | i |   |       |           |
| supplemental       | O |     | e |          | o |   |       |           |
| sheet, if          | f |     | O |          | n |   |       |           |
| necessary)*        |   |     | f |          | a |   |       |           |
|                    | B |     | B |          | l |   |       |           |
|                    | i |     | i |          | i |   |       |           |
|                    | r |     | r |          | t |   |       |           |
|                    | t |     | t |          | y |   |       |           |
|                    | h |     | h |          |   |   |       |           |
|                    |   |     |   |          |   |   |       |           |
|                    |   |     | * |          |   |   |       |           |
|                    |   |     | ( |          |   |   |       |           |
|                    |   |     | c |          |   |   |       |           |
|                    |   |     | i |          |   |   |       |           |
|                    |   |     | t |          |   |   |       |           |
|                    |   |     | y |          |   |   |       |           |
|                    |   |     | a |          |   |   |       |           |
|                    |   |     | n |          |   |   |       |           |
|                    |   |     | d |          |   |   |       |           |
|                    |   |     | c |          |   |   |       |           |
|                    |   |     | o |          |   |   |       |           |
|                    |   |     | u |          |   |   |       |           |
|                    |   |     | n |          |   |   |       |           |
|                    |   |     | t |          |   |   |       |           |
|                    |   |     | r |          |   |   |       |           |
|                    |   |     | y |          |   |   |       |           |
|                    |   |     | ) |          |   |   |       |           |
|                    |   |     | * |          |   |   |       |           |
+--------------------+---+-----+---+----------+---+---+-------+-----------+
|                    |   |     |   |          |   |   |       |           |
|                    |   |     |   |          |   |   |       |           |
|                    |   |     |   |          |   |   |       |           |
|                    |   |     |   |          |   |   |       |           |
|                    |   |     |   |          |   |   |       |           |
+--------------------+---+-----+---+----------+---+---+-------+-----------+
|                    |   |     |   |          |   |   |       |           |
|                    |   |     |   |          |   |   |       |           |
|                    |   |     |   |          |   |   |       |           |
|                    |   |     |   |          |   |   |       |           |
|                    |   |     |   |          |   |   |       |           |
+--------------------+---+-----+---+----------+---+---+-------+-----------+
|                    |   |     |   |          |   |   |       |           |
|                    |   |     |   |          |   |   |       |           |
|                    |   |     |   |          |   |   |       |           |
|                    |   |     |   |          |   |   |       |           |
|                    |   |     |   |          |   |   |       |           |
+--------------------+---+-----+---+----------+---+---+-------+-----------+
|                    |   |     |   |          |   |   |       |           |
|                    |   |     |   |          |   |   |       |           |
|                    |   |     |   |          |   |   |       |           |
|                    |   |     |   |          |   |   |       |           |
|                    |   |     |   |          |   |   |       |           |
+--------------------+---+-----+---+----------+---+---+-------+-----------+
|                    |   |     |   |          |   |   |       |           |
|                    |   |     |   |          |   |   |       |           |
|                    |   |     |   |          |   |   |       |           |
|                    |   |     |   |          |   |   |       |           |
|                    |   |     |   |          |   |   |       |           |
+--------------------+---+-----+---+----------+---+---+-------+-----------+
| 10\. Identify      |   |     |   |          |   |   |       |           |
| Source and Amount  |   |     |   |          |   |   |       |           |
| of Funds Available |   |     |   |          |   |   |       |           |
|                    |   |     |   |          |   |   |       |           |
|                    |   |     |   |          |   |   |       |           |
+--------------------+---+-----+---+----------+---+---+-------+-----------+
| 11\. I understand  |   |     |   |          |   |   |       |           |
| that the following |   |     |   |          |   |   |       |           |
| conditions and     |   |     |   |          |   |   |       |           |
| regulations will   |   |     |   |          |   |   |       |           |
| apply if           |   |     |   |          |   |   |       |           |
| permission is      |   |     |   |          |   |   |       |           |
| granted for the    |   |     |   |          |   |   |       |           |
| above-named        |   |     |   |          |   |   |       |           |
| dependents to      |   |     |   |          |   |   |       |           |
|                    |   |     |   |          |   |   |       |           |
| join me, and that  |   |     |   |          |   |   |       |           |
| if I violate any   |   |     |   |          |   |   |       |           |
| of these           |   |     |   |          |   |   |       |           |
| conditions, my     |   |     |   |          |   |   |       |           |
| program may be     |   |     |   |          |   |   |       |           |
| terminated.        |   |     |   |          |   |   |       |           |
+--------------------+---+-----+---+----------+---+---+-------+-----------+
| 1.  **USAID is not |   |     |   |          |   |   |       |           |
|     responsible    |   |     |   |          |   |   |       |           |
|     for travel     |   |     |   |          |   |   |       |           |
|     arrangements,  |   |     |   |          |   |   |       |           |
|     hotel          |   |     |   |          |   |   |       |           |
|     reservations,  |   |     |   |          |   |   |       |           |
|     or any other   |   |     |   |          |   |   |       |           |
|     administrative |   |     |   |          |   |   |       |           |
|     services or    |   |     |   |          |   |   |       |           |
|     support for my |   |     |   |          |   |   |       |           |
|     dependents.**  |   |     |   |          |   |   |       |           |
|                    |   |     |   |          |   |   |       |           |
| 2.  **USAID has no |   |     |   |          |   |   |       |           |
|     financial      |   |     |   |          |   |   |       |           |
|     responsibility |   |     |   |          |   |   |       |           |
|     for the        |   |     |   |          |   |   |       |           |
|     travel,        |   |     |   |          |   |   |       |           |
|     medical needs, |   |     |   |          |   |   |       |           |
|     insurance, or  |   |     |   |          |   |   |       |           |
|     maintenance of |   |     |   |          |   |   |       |           |
|     my dependents, |   |     |   |          |   |   |       |           |
|     and I will not |   |     |   |          |   |   |       |           |
|     receive any    |   |     |   |          |   |   |       |           |
|     additional     |   |     |   |          |   |   |       |           |
|     allowances or  |   |     |   |          |   |   |       |           |
|     special        |   |     |   |          |   |   |       |           |
|     programming    |   |     |   |          |   |   |       |           |
|     from USAID     |   |     |   |          |   |   |       |           |
|     because of     |   |     |   |          |   |   |       |           |
|     them.**        |   |     |   |          |   |   |       |           |
|                    |   |     |   |          |   |   |       |           |
| 3.  **USAID will   |   |     |   |          |   |   |       |           |
|     not continue   |   |     |   |          |   |   |       |           |
|     my maintenance |   |     |   |          |   |   |       |           |
|     allowance      |   |     |   |          |   |   |       |           |
|     beyond the     |   |     |   |          |   |   |       |           |
|     normal         |   |     |   |          |   |   |       |           |
|     termination    |   |     |   |          |   |   |       |           |
|     date of my     |   |     |   |          |   |   |       |           |
|     program if my  |   |     |   |          |   |   |       |           |
|     normal         |   |     |   |          |   |   |       |           |
|     departure date |   |     |   |          |   |   |       |           |
|     is delayed on  |   |     |   |          |   |   |       |           |
|     account of my  |   |     |   |          |   |   |       |           |
|     dependents.**  |   |     |   |          |   |   |       |           |
|                    |   |     |   |          |   |   |       |           |
| 4.  **My           |   |     |   |          |   |   |       |           |
|     dependents     |   |     |   |          |   |   |       |           |
|     will have no   |   |     |   |          |   |   |       |           |
|     official       |   |     |   |          |   |   |       |           |
|     status and     |   |     |   |          |   |   |       |           |
|     will not       |   |     |   |          |   |   |       |           |
|     accompany me   |   |     |   |          |   |   |       |           |
|     on official    |   |     |   |          |   |   |       |           |
|     visits to      |   |     |   |          |   |   |       |           |
|     training       |   |     |   |          |   |   |       |           |
|     facilities.**  |   |     |   |          |   |   |       |           |
|                    |   |     |   |          |   |   |       |           |
| 5.  **I will       |   |     |   |          |   |   |       |           |
|     provide health |   |     |   |          |   |   |       |           |
|     insurance for  |   |     |   |          |   |   |       |           |
|     my dependents  |   |     |   |          |   |   |       |           |
|     prior to their |   |     |   |          |   |   |       |           |
|     departure from |   |     |   |          |   |   |       |           |
|     their home     |   |     |   |          |   |   |       |           |
|     country.**     |   |     |   |          |   |   |       |           |
|                    |   |     |   |          |   |   |       |           |
| 6.  **I will       |   |     |   |          |   |   |       |           |
|     furnish proof  |   |     |   |          |   |   |       |           |
|     that my        |   |     |   |          |   |   |       |           |
|     dependents are |   |     |   |          |   |   |       |           |
|     in good        |   |     |   |          |   |   |       |           |
|     physical       |   |     |   |          |   |   |       |           |
|     health.**      |   |     |   |          |   |   |       |           |
|                    |   |     |   |          |   |   |       |           |
| 7.  **I will be    |   |     |   |          |   |   |       |           |
|     responsible    |   |     |   |          |   |   |       |           |
|     for the cost   |   |     |   |          |   |   |       |           |
|     of round trip  |   |     |   |          |   |   |       |           |
|     international  |   |     |   |          |   |   |       |           |
|     travel for all |   |     |   |          |   |   |       |           |
|     of my          |   |     |   |          |   |   |       |           |
|     dependents.**  |   |     |   |          |   |   |       |           |
|                    |   |     |   |          |   |   |       |           |
| 8.  **I will not   |   |     |   |          |   |   |       |           |
|     permit my      |   |     |   |          |   |   |       |           |
|     dependents to  |   |     |   |          |   |   |       |           |
|     interfere with |   |     |   |          |   |   |       |           |
|     my program in  |   |     |   |          |   |   |       |           |
|     any way.**     |   |     |   |          |   |   |       |           |
|                    |   |     |   |          |   |   |       |           |
| 9.  **I will not   |   |     |   |          |   |   |       |           |
|     permit any of  |   |     |   |          |   |   |       |           |
|     my dependents  |   |     |   |          |   |   |       |           |
|     to apply for   |   |     |   |          |   |   |       |           |
|     or accept any  |   |     |   |          |   |   |       |           |
|     public welfare |   |     |   |          |   |   |       |           |
|     funds in the   |   |     |   |          |   |   |       |           |
|     country or     |   |     |   |          |   |   |       |           |
|     local          |   |     |   |          |   |   |       |           |
|     jurisdiction   |   |     |   |          |   |   |       |           |
|     of training.** |   |     |   |          |   |   |       |           |
+--------------------+---+-----+---+----------+---+---+-------+-----------+
| Signature of       |   |     |   |          |   | D |       |           |
| Participant        |   |     |   |          |   | a |       |           |
|                    |   |     |   |          |   | t |       |           |
|                    |   |     |   |          |   | e |       |           |
+--------------------+---+-----+---+----------+---+---+-------+-----------+
| Name of USAID      |   | Sig |   |          |   | O |       |           |
| Official           |   | nat |   |          |   | f |       |           |
|                    |   | ure |   |          |   | f |       |           |
|                    |   |     |   |          |   | i |       |           |
|                    |   |     |   |          |   | c |       |           |
|                    |   |     |   |          |   | i |       |           |
|                    |   |     |   |          |   | a |       |           |
|                    |   |     |   |          |   | l |       |           |
|                    |   |     |   |          |   | T |       |           |
|                    |   |     |   |          |   | i |       |           |
|                    |   |     |   |          |   | t |       |           |
|                    |   |     |   |          |   | l |       |           |
|                    |   |     |   |          |   | e |       |           |
+--------------------+---+-----+---+----------+---+---+-------+-----------+

AID 1380-5 (03/05)