Form SD template draft

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From the 12th Conflict-Free Sourcing Initiative Workshop: Form SD template draft

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Form SD template draft

  1. 1. 1 DRAFT - FOR DISCUSSION PURPOSES ONLY UNITED STATES SECURITIES AND EXCHANGE COMMISSION Washington, D.C. 20549 FORM SD SPECIALIZED DISCLOSURE REPORT Company X (Exact name of the registrant as specified in its charter) State ###-##### ##-####### (State or other jurisdiction of incorporation or organization) (Commission File Number) (IRS Employer Identification No.) 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___. Introduction: Brief description of Company X and the product(s) it produces. Some content pulled from company 10k statement. 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.
  2. 2. 2 DRAFT - FOR DISCUSSION PURPOSES ONLY 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 information. 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 Tin Tbd Tungsten Tbd Gold Tbd 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> * * * * *
  3. 3. 3 DRAFT - FOR DISCUSSION PURPOSES ONLY SIGNATURES 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________________ (Registrant) _____________________________________________________ ________________________ 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. * * * * *

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