ࡱ> |yz{ 0bjbj 4@- 88888LLL84lL?$|!"!!!"""0>2>2>2>2>2>2>$A*>8""""">88!!4?$***"8!8!0>*"0>**45!ʻW#4>?<?5mDT$mD558mD85D""*"""""V>V>'"""?""""mD""""""""" : STANDARD FORM FOR LISTING OF GROUPS ON THE ISIL (DAESH) AND AL-QAIDA SANCTIONS LIST Member States are requested to provide the following information to allow for the accurate and positive identification of the group. Please leave blank any fields for which information is not available. For additional information or assistance in completing the form, please contact the Analytical Support and Sanctions Monitoring Team at : email: HYPERLINK "mailto:1267MT@un.org" 1267MT@un.org, telephone: 917-367-2315. I.A. KEY IDENTIFYING INFORMATION Full name (this is the main name under which the group will be listed)(in Latin script)Original script (if not Latin): Indicate script (for example, Arabic, Chinese, Russian):Full name in other scripts (indicate scripts, for example, Arabic, Chinese, Russian):Acronym (if applicable)(in Latin script)Original script (if not Latin): Indicate script (for example, Arabic, Chinese, Russian):Other scripts ( indicate scripts, for example, Arabic, Chinese, Russian): EstablishmentPlace (street, city, state/province, country): Day: Month: Year: Calendar: Operational areasPlace (street, city, state/province, country): Time frame (Month/Year Month/Year): Calendar: Place (street, city, state/province, country): Time frame (Month/Year Month/Year): Calendar: Place (street, city, state/province, country): Time frame (Month/Year Month/Year): Calendar: Addresses (if applicable)Current (street, city, state/province, country): Dates: Previous (street, city, state/province, country): Dates:  I.B. ALIASES/AKAS/FKAS Please leave blank any fields for which information in not available.Also-Known-As (AKA) (including Formerly-Known-As (FKA) names)(in Latin script)Original script (if not Latin) Indicate script (for example, Arabic, Chinese, Russian):Other scripts (if applicable): Type of AKA FORMCHECKBOX  Name variation  FORMCHECKBOX  Spelling variation  FORMCHECKBOX  Formerly-Known-As (FKA)  FORMCHECKBOX  Other, explain:Acronym (if applicable)(in Latin script):Original script (if not Latin): Indicate script (for example, Arabic, Chinese, Russian):Other scripts (if applicable): Other information relevant to this AKA  Also-Known-As (AKA) (including Formerly-Known-As (FKA) names)(in Latin script)Original script (if not Latin) Indicate script (for example, Arabic, Chinese, Russian):Other scripts (if applicable): Type of AKA FORMCHECKBOX  Name variation  FORMCHECKBOX  Spelling variation  FORMCHECKBOX  Formerly-Known-As (FKA)  FORMCHECKBOX  Other, explain:Acronym (if applicable)(in Latin script):Original script (if not Latin): Indicate script (for example, Arabic, Chinese, Russian):Other scripts (if applicable): Other information relevant to this AKA  Also-Known-As (AKA) (including Formerly-Known-As (FKA) names)(in Latin script)Original script (if not Latin) Indicate script (for example, Arabic, Chinese, Russian):Other scripts (if applicable): Type of AKA FORMCHECKBOX  Name variation  FORMCHECKBOX  Spelling variation  FORMCHECKBOX  Formerly-Known-As (FKA)  FORMCHECKBOX  Other, explain:Acronym (if applicable)(in Latin script):Original script (if not Latin): Indicate script (for example, Arabic, Chinese, Russian):Other scripts (if applicable): Other information relevant to this AKA  I.C. Founders, leaders and other key figures Please leave blank any fields for which information in not available.Founder, leader, associate or other key figurePRN(Permanent Reference Number if listed)Full name(in Latin script)Original script (if not Latin) Indicate script (for example, Arabic, Chinese, Russian):Other scripts (if applicable):Birth data Place (street, city, state/province, country): Day:  FORMTEXT    Month:  FORMTEXT    Year:  FORMTEXT      Calendar: Nationality, citizenship (current and past, add dates when granted, revoked, annulled, withdrawn, if known)States of residenceAddress or location (current and past)Place (street, city, state/province, country) and date (day, month, year, calendar):Identity and travel document (describe nationality, type, issued by, issued at, issue date, issued to, place and date of birth as documented)Physical description(male/female, tribal/ethnic background, other details)AKAs(include alias in original/other scripts (describe), type of AKAs (good or low quality), birth data and nationality under each AKAs, any additional information) Any other relevant information Founder, leader, associate or other key figurePRN(Permanent Reference Number if listed)Full name(in Latin script)Original script (if not Latin) Indicate script (for example, Arabic, Chinese, Russian):Other scripts (if applicable):Birth data Place (street, city, state/province, country): Day:  FORMTEXT    Month:  FORMTEXT    Year:  FORMTEXT      Calendar: Nationality, citizenships (current and past, add dates when granted, revoked, annulled, withdrawn, if known)States of residenceAddress or location (current and past)Place (street, city, state/province, country) and date (day, month, year, calendar):Identity and travel document (describe nationality, type, issued by, issued at, issue date, issued to, place and date of birth as documented)Physical description(male/female, tribal/ethnic background, other details)AKAs(include alias in original/other scripts (describe), type of AKAs (good or low quality), birth data and nationality under each AKAs, any additional information) Any other relevant information Founder, leader, associate or other key figurePRN(Permanent Reference Number if listed)Full name(in Latin script)Original script (if not Latin) Indicate script (for example, Arabic, Chinese, Russian):Other scripts (if applicable):Birth data Place (street, city, state/province, country): Day:  FORMTEXT    Month:  FORMTEXT    Year:  FORMTEXT      Calendar: Nationality, citizenship (current and past, add dates when granted, revoked, annulled, withdrawn, if known)States of residenceAddress or location (current and past)Place (street, city, state/province, country) and date (day, month, year, calendar):Identity and travel document (describe nationality, type, issued by, issued at, issue date, issued to, place and date of birth as documented)Physical description(male/female, tribal/ethnic background, other details)AKAs(include alias in original/other scripts (describe), type of AKAs (good or low quality), birth data and nationality under each AKAs, any additional information) Any other relevant information I.D. organizational linkages, associated and affiliated groups, entities and undertakings Please describe all branches, subsidiaries, parent organization and/or sister branches. Please leave blank any fields for which information in not available.Associated and affiliated groups, entities, undertakingsPRN(Permanent Reference Number if listed)Full name(in Latin script)Original script (if not Latin) Indicate script (for example, Arabic, Chinese, Russian):Other scripts (if applicable):Establishment data (multiple, if applicable)Place (street, city, state/province, country) and date (day, month, year, calendar):Address or location (current and past)Place (street, city, state/province, country) and date (day, month, year, calendar):Financial information(known assets, major funding sources)AKAs(include AKAs in original/other scripts (describe), type of AKAs, any additional information) Any other relevant information Associated and affiliated groups, entities, undertakingsPRN(Permanent Reference Number if listed)Full name(in Latin script)Original script (if not Latin) Indicate script (for example, Arabic, Chinese, Russian):Other scripts (if applicable):Establishment data (multiple, if applicable)Place (street, city, state/province, country) and date (day, month, year, calendar):Address or location (current and past)Place (street, city, state/province, country) and date (day, month, year, calendar):Financial information(known assets, major funding sources)AKAs(include AKAs in original/other scripts (describe), type of AKAs, any additional information) Any other relevant information Associated and affiliated groups, entities, undertakingsPRN(Permanent Reference Number if listed)Full name(in Latin script)Original script (if not Latin) Indicate script (for example, Arabic, Chinese, Russian):Other scripts (if applicable):Establishment data (multiple, if applicable)Place (street, city, state/province, country) and date (day, month, year, calendar):Address or location (current and past)Place (street, city, state/province, country) and date (day, month, year, calendar):Financial information(known assets, major funding sources)AKAs(include AKAs in original/other scripts (describe), type of AKAs, any additional information) Any other relevant information I.E. OTHER INFORMATIONStatusOpen and active FORMCHECKBOX  Clandestine FORMCHECKBOX  Merged  FORMCHECKBOX  with which entity:Splintered FORMCHECKBOX  from which entity:Banned/illegal FORMCHECKBOX  Existing INTERPOL Notices (please indicate if there are any INTERPOL notices issued for the group at the request of your authorities)Yes  FORMCHECKBOX  No  FORMCHECKBOX .Not Known  FORMCHECKBOX  If yes, please explain:  FORMTEXT      Website address I.F. FINANCIAL INFORMATIONKnown assets Funds ValueBank accountBank IDStocks, bonds and other financial assets ValueCategory and termRegulators Property ValueAddressRegistration numberRegistration AuthorityOther assets and economic resourcesValueCategoryMajor funding sourcesDonations  FORMCHECKBOX  Proceeds of crimes  FORMCHECKBOX  Others,  FORMCHECKBOX  please explain:  I.G. OTHER INFORMATION NOT SPECIFIED ABOVE  II. BASIS FOR LISTING Member States are requested to indicate in one or more of the fields below the association between the group inscribed in section I of this form and ISIL or Al-Qaida (including on the ISIL (Daesh) and Al-Qaida Sanctions List). Please include the permanent reference number(s) of those names which the group is associated with that already appear on the ISIL (Daesh) and Al-Qaida Sanctions List. In the event of the designation of this group by the Committee, the information provided will be used for the development of the narrative summary of reasons for listing to be published on the Committees website. FORMCHECKBOX  (a) Participating in the financing, planning, facilitating, preparing, or perpetrating of acts or activities by, in conjunction with, under the name of, on behalf of, or in support of Al-Qaida, ISIL, or any cell, affiliate, splinter group or derivate thereof; Name(s) and permanent reference number(s) on the ISIL (Daesh) and Al-Qaida Sanctions List (if applicable): FORMTEXT         FORMCHECKBOX  (b) Supplying, selling or transferring arms and related materiel to Al-Qaida, ISIL, or any cell, affiliate, splinter group or derivate thereof; " Name(s) and permanent reference number(s) on the ISIL (Da esh) and Al-Qaida Sanctions List (if applicable): FORMTEXT        FORMCHECKBOX  (c) Recruiting for Al-Qaida, ISIL, or any cell, affiliate, splinter group or derivate thereof; " Name(s) and permanent reference number(s) on the ISIL (Da esh) and Al-Qaida Sanctions List (if applicable): FORMTEXT        FORMCHECKBOX  (d) otherwise supporting acts or activities of Al-Qaida, ISIL, or any cell, affiliate, splinter group or derivate thereof; " Name(s) and permanent reference number(s) on the ISIL (Da esh) and Al-Qaida Sanctions List (if applicable): FORMTEXT        FORMCHECKBOX  (e) either owned or controlled, directly or indirectly, by, or otherwise supporting, any individual, group, undertaking or entity associated with Al-Qaida or ISIL, including on the ISIL (Da esh) and Al-Qaida Sanctions List. 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STATEMENT OF CASE (RELEASABLE UPON REQUEST) The statement of case should provide as much detail as possible on the basis(es) for listing, including: (i) specific information supporting a determination that the group meets the criteria above; (ii) the nature of the information, for example, intelligence, law enforcement, judicial, media, and admissions by subject; and (iii) additional information or documents provided with the submission. States should include details of any connection between the group proposed for listing and any currently listed individual or entity. III.B. PARTS OF STATEMENT OF CASE IDENTIFIED AS BEING CONFIDENTIAL TO THE COMMITTEE  IV. IDENTITY OF DESIGNATING STATE Pursuant to paragraph 46 of resolution 2253 (2015), Member States proposing a new listing shall specify if the Committee or the Ombudsperson may not make known the Member States status as a designating State.Specify if the Committee or the Ombudsperson:  FORMCHECKBOX  May make known the Member States status as a designating State  FORMCHECKBOX  May not make known the Member States status as a designating State  V. INTERPOL COOPERATION Pursuant to paragraph 45 of resolution 2253 (2015), Member States shall provide the Committee with as much relevant information as possible on the proposed name, in particular sufficient identifying information to allow for the accurate and positive identification of individuals, groups, undertakings and entities, and to the extent possible, the information required by INTERPOL to issue a INTERPOL-51Թ Security Council Special Notice.INTERPOL may for implementation purposes wish to contact the relevant authorities in your country, with a view to obtaining additional information on the group proposed for designation herewith. For this purpose, please indicate below if the Committee may inform INTERPOL, upon INTERPOLs request, that your country is a designating State of the above-mentioned group (INTERPOL would then contact your countrys permanent mission to the 51Թ in New York with the relevant inquiries).  FORMCHECKBOX  Yes  FORMCHECKBOX  No In addition, please indicate below if the Committee may convey to INTERPOL, upon INTERPOLs request, the details of the point of contact below within your Government (INTERPOL may then contact directly the contact point below with the relevant inquiries).  FORMCHECKBOX  Yes  FORMCHECKBOX  No  VI. 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