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SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549
SPECIALIZED DISCLOSURE REPORT
(Exact name of the registrant as specified in its charter)
State ###-##### ##-#######
(State or other jurisdiction of
incorporation or organization)
Company address company zip code
(Address of principal executive offices) (Zip code)
Name of Corporate Secretary contact phone number
(Name and telephone number, including area code, of the
person to contact in connection with this report.)
Check the appropriate box to indicate the rule pursuant to which this form is being filed, and provide the
period to which the information in this form applies:
_√__ Rule 13p-1 under the Securities Exchange Act (17 CFR 240.13p-1) for the reporting period from
January 1 to December 31, _2013___.
Brief description of Company X and the product(s) it produces. Some content pulled from company 10k
Brief description of product categories, widgets which relate to the each product category, statement that
the widgets contain necessary conflict minerals and how those necessary conflict minerals are sourced and
ultimately incorporated into the widgets via the company’s own and outsourced manufacturing process for
the main company and as needed, clarification on subsidiaries.
Statement and hyperlink to company’s publically available Conflict Minerals Policy.
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Section 1 - Conflict Minerals Disclosures
In accordance with the execution of this policy, Company X has concluded in good faith that during 20xx,
a) Company X has manufactured and contracted to manufacture products as to which “conflict
minerals” (as defined in Section 1, Item 1.01 (d)(3) of Form SD) are necessary to the functionality
or production of such products.
b) Based on a “reasonable country of origin inquiry” Company X knows or has reason to believe that a
portion of its necessary conflict minerals originated or may have originated in the Democratic
Republic of the Congo or an adjoining country (collectively, sometimes referred to as the “Covered
Countries”) and knows or has reason to believe that those necessary conflict minerals may not be
from recycle or scrap sources.
Company X’s reasonable country of origin inquiry (RCOI) employed a combination of measures to
determine whether the necessary conflict minerals in Company X products originated from the Covered
Countries. Company X’s primary means of determining country of origin of necessary conflict minerals
was by conducting a supply-chain survey with direct suppliers using the EICC/GeSI Conflict Minerals
Reporting Template. Company X surveyed ##% of our direct suppliers representing >##% of total
procurement activities. Additionally, Company X’s participation with in-region sourcing programs such
as Solutions for Hope [reference information to be added] provided additional country of origin
As a result of the reasonable country of origin inquiry conducted as described above, all Company X
suppliers who contribute necessary conflict minerals to Product Category A have provided a response to
the supply-chain survey. Approximately ##% of Company X suppliers, representing approximately
##% of procurement activities who contribute necessary conflict minerals to Product Category B have
provided a response to the supply-chain survey. Below is a summary of the information collected from
all supply-chain survey respondents.
Conflict Mineral Countries of origin may include the following
Tantalum Democratic Republic of the Congo
In accord with Rule 13p-1 under the Securities Exchange Act of 1934 (‘Rule 13p-1”), Company X has
filed this Specialized Disclosure Form (Form SD) and the associated Conflict Minerals Report and both
reports are posted to a publically available Internet site at <insert hyperlink>.
Section 2 – Exhibits
Exhibit 1.01 – Conflict Minerals Report as required by Items 1.01 and 1.02 of this Form.
<insert Conflict Minerals Report>
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Pursuant to the requirements of the Securities Exchange Act of 1934, the registrant has duly caused this
report to be signed on its behalf by the duly authorized undersigned.
_____COMPANY X CORPORATION________________
By (Signature and Title)* (Date)
Name and Title (printed)
*Print name and title of the registrant’s signing executive officer under his or her signature.
* * * * *