The supplier hereby acknowledges that the sum claimed on the accompanying invoice to be doe and owing under the terms of the purchase contract identified on the reverse hereof ("said contract') is to be paid, in whole or in part, out of funds made available by the United States Agency for laternational Development (A.I.D.) under the Foreign Assistance Act of 1961, as amended. In consideration of the receipt of such sum, the supplier agrees with and certifies to A.I.D. as follows:

1. The undersigned is the supplier of the commodities or commodity-related services indicated in the Invoice-and-Contract Abstract on the reverse hereof, has complied with the applicable provisions of Regulation 1 (22 CFR Pari 201), as in effect on the date hereof is entitled under said contract and under the applicable' letter of credit, credit advice, or other payment instructions to payment of the sum claimed, and is executing this Certificate and Agreement to obtain such payment from A.1.D. funds.

2. 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, the purchase price is not higher than the maximum price permitted under each of the applicable price rules of suabpart G of A.I.D. Regulation 1.

4.

The supplier will, upon request of A.I.D., promptly make appropriate refund to A.I.D., plus Interest from the time of payment to the supplier, in the event of

(a) its nonperformance, in whole or in part, under said contract, or including any failure to pay despatch or

(b) any breach by it of any of its undertakings in this Certificate and Agreement, or

(c) any false certification or representation made by it in this Certificate and Agreement or in the Invoice-and-Contract Abstract on the reverse hereof.

5. The amount shown on the reverse hereof in block 9c is not of all trade discounts, whether in the form of payments, credits, or allowances by the supplier or its agent to or for the account of the Importer, including quantity and prompt payment discounts allowed other customers under similar efremstances. The supplier will promptly pay to A.1.D. (Office of Financial Management, A.1.D.. Washington, D. C. 20523-0209) any adjustment refunds, credita, or allowances which bereafter become payable to or for the account of the Importer arising out of the terms of said contract or the customs the trade.

1. Any commodity supplied under sald contract

(a) is accurately described on the reverse hereof and, unless otherwise authorised by A.I.D., is new and unused, is not rebuilt of reconditioned, does not contain any rebulk 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 avaliable to the supplier upon reasonable investigation, and to the best of its Information and belief, meets the requirements of Section 201.11(b) of A.1.D. Regulation 1 as to source, country where mined, Brown, or produced, and limitation en components.

13. The commodity supplier certifies that it has every ocean bill of lading. applicable to the transactions described on the reverse hereof to: (1) the Administration, National Carge Division, 400 Seventh Street, S. W. Washington, D. C. 20390-0001; and (11) Office Procure Transportation Division, A.I.D., Washington, D. C. 20533-1419; and that such bill(s) of lading state all the carrier's charges including the basis for calculation such as weight or cubic monsUOMENIS,

14. The supplier has filed in all applicable portions of the Invoice-and-Contract Abstract on the reverse hereof and cartides to the completeness and correctness of the information shown therein. PERSONAL CERtification by NATURAL PERSON SIGNING THIS CERTIFICATE AND AGREEMENT Certificate

The natural person whe certifies either that he/she authority to sign on behalf of regard to all certifications and and Agreement. He/she further supplier, that he/she is either an written power of attorney to sign for and acknowledges signing and submitting this receive payment from A.I.D. funds and that A. payment will rely on the truth and accuracy of this Personal Carut as well as of all other representations in this Certificate and Agreeme

NOTES: (a) Any amendments of or additions to the printed of this Supplier's Certificate and Agreement are be considered a part hereof. (b) False stateme by United States Law. (c) The word "Copy” mu signature on all copies other than the original.

after the

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PAPERWORK REDUCTION ACT NOTICE. Information furnished will be used to verify compliance with legal requirements, as a basis for recourse in the event of noncompliance, and to monitor participation in A.1.D. programs. It will be disclosed outside A.1.D. only as provided by law. Submission of this information has been determined to be necessary to receive payment from A.1.D. funds pursuant to 22 U.S.C. 2381.

Public reporting burden for this collection of information is estimated to average thirty 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:

Agency For International Development

Office of Procurement Policy. Planning

& Evaluation, MS/PPE

Washington, D. C. 20523–1435;

and

Office of Management and Budget

Paperwork Reduction Project (0412-0020) Washington, D. C. 20503

EXECUTION OF FORM. This form is designed for use with the U.S. Standard Master for International Trade. An original and one (1) copy of this form, completed by the following suppliers, as applicable, must accompany each invoice for which payment is requested:

(a) Commodity Supplier - executed by the commodity supplier covering the cost of the commodity, including the cost of any commodity-related service paid by the commodity supplier for its own or the buyer's account;

(b) Transportation Supplier (Carrier) – executed by each carrier or in the case of a through Bill of Lading, the issuing carrier, for the cost of the ocean or air transportation financed by A.I.D., whether or not the transportation is paid by the commodity supplier;

(c) Insurance Supplier (Insurer) – executed by the insurer (or under the circumstances set forth in Section 201.52(b) (2) of A.I.D. Regulation 1, by an insurance broker or the commodity supplier). whether or not the insurance is paid by the commodity supplier, for the cost of marine insurance financed by A.I.D. when such cost exceeds $50.

The original must be signed by a person authorized by the supplier who shall indicate his/her title and certify to his/her authority.

LANGUAGE. The form must be completed in the English language only and all amounts of money must be shown in U.S. dollars.

OBTAINING FORMS. The form (as well copies of A.1.D. Regulation i referenced in this form) may be obtained in limited quantities from banks holding A.I.D. Letters of Commitment, from district offices of the Department of Commerce, the A.I.D. office in the supplier's country, or the Resources Management Division, Agency for International Development, Washington, D. C. 20523-1410. The form may be reproduced, providing the reproduction is identical in size and format.

INSTRUCTIONS FOR COMPLETING ENTRIES ON INVOICEAND-CONTRACT ABSTRACT

GENERAL INSTRUCTIONS

Except as provided in the instructions for specific blocks, suppliers must complete all blocks or enter the letters 'NA" (Not Applicable). as follows:

Commodity,Supplier - Complete all Blocks except 12 and 13; however, if the commodity supplier has paid for the transportation and/or insurance for its own or the buyer's account, Blocks 12 and/or 13 will also be completed by the commodity supplier. Block 11 is to be completed only when the address in block 1 is a U.S. address.

Transportation Supplier (Carrier) - Complete Blocks 1 through 8 as well as 13, 14, and 16.

Insurance Supplier (Insurer) - Complete Blocks 1 through 8a as well as 12, 14, and 16.

INSTRUCTIONS FOR INDIVIDUAL BLOCKS

Block 1: Enter the commodity supplier's name and address.

a Indicate whether the supplier is a small business concern as defined in FAR 19.101 (CFR Title 48). "Small business concern” means a concern, including its affiliates, that is independently owned and operated (for profit), not dominant in its field of operations, and qualified as a small business under the criteria and size standards in 13 CFR 121 ( FAR 19.102). If there is no size standard in 13 CFR 121 for the Industry, field of operation, or activity in which a concern is engaged, the concern is a small business if, including its affiliates, it is independently owned and operated (for profit), is not dominant in the field of operation, and, for manufacturing concerns -- has no more than 300 employees, or for concerns offering services -- its average annual receipts for its preceding 3 fiscal years do not exceed $3.5 million.

b. If the supplier is not a 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 small business concerns.

c. Indicate whether the supplier is an socially and economically disadvantaged enterprise. "Socially and economically disadvantaged enterprise" means a business

(1) which is at least 51 percent owned by one or more socially and economically disadvantaged individuals or, in the case of a publicly owned business, at least 51 percent of the stock of which is owned by one or more socially disadvantaged Individuals, and (ii) whose management and daily business operations are controlled by one or more such individuals.

"Socially disadvantaged" individuals are those who have been subjected to racial or ethnic prejudice or cultural bias because of their identity as a member of a group without regard to their qualities as Individuals.

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"Economically disadvantaged individuals" means socially disadvantaged individuals whose ability to compete in the free enterprise system is impaired due to diminished opportunities to obtain capital and credit as compared to others in the same line of business who are not socially disadvantaged. Women and individuals who certify that they are members of named groups (Black Americans. Hispanic Americans, Native Americans, Asian-Pacific Americans, Subcontinent-Asian Americans) are to be considered socially and economically disadvantaged.

*Subcontinent Asian Americans" means United States citizens whose origins are in India, Pakistan, Bangladesh, Sri Lanka, Bbutan, or Nepal.

"Asian Pacific Americans" means United States citizens whose origins are in Japan, China, the Philippines, Vietnam, Kores. Samoa, Guam, the U.S. Trast Territory of the Pacific Islands (Republic of Palau), the Northern Mariana Islands, Laos, Kampuchea (Cambodia), Taiwan, Burma, Thailand, Malaysia, Indonesia, Singapore, Brunei, Republic of the Marshall Islands, or the Federated States of Micronesia.

"Native Americans" means American Indians, Eskimos, Aleuts, and native Hawaiians.

4. If the supplier is not a socially and economically disadvantaged enterprise, 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 socially and economically disadvantaged enterprises.

⚫. Indicate whether the supplier is a women-owned business: "Women-owned business" means a business which is at least 51 percent owned by one or more women who are United States citions and who also control and operate the business.

f. If the supplier is not a women-owned business, enter the best estimate of the percentage of the total involes amount paid or to be paid to subcontractors or suppliers of components who are women-owned businesses.

BLOCK 12: INSURANCE INFORMATION COMPLETE BLOCK 12 only if the insurance premium exceeds $50. a. Enter the insured value of the shipment. b. Enter the total premium.

c. Enter the type of coverage and insurance rate. " "Other" is checked, explain below or in Block 15.

BLOCK 13: TRANSPORTATION INFORMATION
a. Check vessel type.

b. Enter Bill of Lading or air waybill number.
c. Enter Bill of Lading or air waybill date.

d. Enter the freight rate, other freight charges and the total dollar amount of freight charges after discount. BLOCK 14: INFORMATION AS TO COMMISSIONS, CREDIT, ALLOWANCES, SIMILAR PAYMENTS AND SIDE PAYMENTS Enter Information on (a) all commissions and other payments, credits, allowances or benefits of any kind, paid or to be paid by the supplier to or for the benefit of its agent, the importer, or the importer's agent as required by Section 201.65 of A.I.D. Regulation 1; and (b) any side payments, not shown on the invoice, made or to be made by the importer to the supplier, in connection with the transaction, as required by Section 201.66 of A.I.D. Regulation 1. If there is insufficient space to furnish the required information in block 14, continue in block 15 or enter "Continued" or "See attached" in block 148, and attach a separate sheet to the form. If no commissions or other payments, credits, allowances, banaktis, or side payments are involved, enter "NONE" in block 14.

BLOCK 16: If the Supplier's Certificate is completed by the carrier or Insurer, check the appropriate box and print or type carrier's or insurer's name and address.

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AID 11 (6-80) Back

15. Remarks and Additional information

OMB No. 0412-0004 Expiration Date: 6/31/93

16.

As a condition for securing a determination of commodity eligibility for funds made available by the United States under the Foreign Assistance Act of 1961, as amended, in payment in whole or in part In the transaction described and for the commodity Identified on this form, the undersigned, acting on behalf of the supplier whose name appears in block 5 above and authorized to bind the supplier, agrees with and certifies to A.I.D. as folows:

1. The supplier has contracted with the Importer named in block 6 for the purchase of the commodity described on this form, and the supplier has other attached to this form & copy of such contract or has furnished in block 2 Information concerning a letter of credit confirmed or advised in ite favor under a payment obligation assumed by the importer in the contract.

2. The supplier has filled in the applicable portions of this form and certifies to the correctness of the Information shown herein.

3. The supplier agrees that the commodity will be shipped and Invoiced in accordance with the information shown herein; that if any change in commodity Identification takes place after A.I.D. has approved this transaction, the supplier will resubmit this form to A.I.D. for review and further approval for financing in light of the changed commodity: and that this Commodity Approval Application which the supplier proposes to use as a basis for securing payment from A.I.D. unde, is in every respect the original or true copy of the original application approved by A.I.D. The supplier acknowledgee that any commodity, other than a commodity described on this form by the supplier and approved by A.I.D. below, le ineligible for A.I.D. financing with respect to the purchase transaction for which this form must be submitted as a condition for payment.

4. The supplier certifies that it is an individual citizen or lawfully admitted permanent resident of a country included in the authorized

17.

Typed or Printed Name and Title

nized

source code; a corporation or partners of a country included in the authorized of business in such country; or a (within the meaning of $967 et seq. as attested by current Information on Service of the United States (on IRS Fo substitute or successor forms) submitt corporation, or a joint venture or unincorp eleting entirely of individuals, corporatione any of the foregoing categories. If the foreign corporation without a regular place of States, the supplier appoints any shareholder agent for the supplier to receive service of pro States in connection with any dispute arising between

con

roled

United

thereof

and A.I.D. and relating to the commodity sale financed by A.I.D.

Typed or Printed Name and Title

Date