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Required Fields Answer provided Notes Hyperlink to source necessary? complete? incomplete comment1 comment for remaining
Company Name (*): Metal Surfaces, Inc. Complete

1     Complete Provide your company name on the Declaration tab cell D8
Declaration Scope or Class (*): A. Company Complete

1     Complete Select the scope of declaration on the Declaration tab cell D9
Description of Scope: Company wide Complete

      Complete Provide description of scope on Declaration tab cell D10
Contact Name (*): Teresa Bell Complete

1     Complete Provide contact name in Declaration tab cell D15
Email – Contact (*): tbell@metalsurfaces.com Complete

1     Complete Provide a valid email for contact in Declaration tab cell D16
Phone – Contact (*): 562-927-1331 Complete

1     Complete Provide a phone number for contact in Declaration tab cell D17
Authorizer (*): Teresa Bell Complete

1     Complete Provide authorized company representative contact name in Declaration tab cell D18
Email - Authorizer (*): tbell@metalsurfaces.com Complete

1     Complete Provide an email for authorized company representative on Declaration tab cell D20
Phone - Authorizer (*): 562-927-1331 Complete

1     Complete Provide a phone number for authorized company representative on Declaration tab cell D21
Effective Date (*): 15-Aug-2017 Complete

1     Complete Provide date the form was completed on Declaration tab cell D22
1) Is any 3TG intentionally added or used in the product(s) or in the production process? (*)      



Tantalum   No Complete
1     Complete Declare if Tantalum is intentionally added to your products on Declaration tab cell D26
Tin  (*) Yes Complete

1     Complete Declare if Tin is intentionally added to your products on Declaration tab cell D27
Gold  (*) Yes Complete

1     Complete Declare if Gold is intentionally added to your products on Declaration tab cell D28
Tungsten   No Complete

1     Complete Declare if Tungsten is intentionally added to your products on Declaration tab cell D29
2) Does any 3TG remain in the product(s)? (*)      


 
Tantalum     Complete

  1   Complete Declare if Tantalum is necessary to the production of your products and contained within the finished products declared in Declaration tab cell D32
Tin  (*) Yes Complete

1     Complete Declare if Tin is necessary to the production of your products and contained within the finished products declared in Declaration tab cell D33
Gold  (*) Yes Complete

1     Complete Declare if Gold is necessary to the production of your products and contained within the finished products declared in Declaration tab cell D34
Tungsten     Complete

  1   Complete Declare if Tungsten is necessary to the production of your products and contained within the finished products declared in Declaration tab cell D35
3) Do any of the smelters in your supply chain source the 3TG from the covered countries? (SEC term, see definitions tab) (*)      

 
Tantalum     Complete

  1   Complete Declare if Tantalum used within the scope of products declared within this survey response originated from the DRC or an adjoining Country on the Declaration tab cell D38
Tin  (*) No Complete

1     Complete Declare if Tin used within the scope of products declared within this survey response originated from the DRC or an adjoining Country on the Declaration tab cell D39
Gold  (*) No Complete

1     Complete Declare if Gold used within the scope of products declared within this survey response originated from the DRC or an adjoining Country on the Declaration tab cell D40
Tungsten     Complete

  1   Complete Declare if Tungsten used within the scope of products declared within this survey response originated from the DRC or an adjoining Country on the Declaration tab cell D41
4) Does 100 percent of the 3TG (necessary to the functionality or production of your products) originate from recycled or scrap sources?  (*)      

 
Tantalum     Complete

  1   Complete Declare if Tantalum used within the scope of products declared within this survey response originated entirely from a recycled or scrap source on the Declaration tab cell D44
Tin  (*) No Complete

1     Complete Declare if Tin used within the scope of products declared within this survey response originated entirely from a recycled or scrap source on the Declaration tab cell D45
Gold  (*) No Complete

1     Complete Declare if Gold used within the scope of products declared within this survey response originated entirely from a recycled or scrap source on the Declaration tab cell D46
Tungsten     Complete

  1   Complete Declare if Tungsten used within the scope of products declared within this survey response originated entirely from a recycled or scrap source on the Declaration tab cell D47
5) What percentage of relevant suppliers have provided a response to your supply chain survey?  (*)      

Tantalum     Complete
  1   Complete Provide % of completeness of supplier's smelter information on Declaration tab cell D50
Tin  (*) 1 Complete
1     Complete Provide % of completeness of supplier's smelter information on Declaration tab cell D51
Gold  (*) 1 Complete
1     Complete Provide % of completeness of supplier's smelter information on Declaration tab cell D52
Tungsten     Complete
  1   Complete Provide % of completeness of supplier's smelter information on Declaration tab cell D53
6) Have you identified all of the smelters supplying the 3TG to your supply chain?  (*)      


Tantalum     Complete


  1   Complete Declare if all smelter names have been provided in this survey response under the scope of products declared on the Declaration tab cell D56
Tin  (*) Yes Complete


1     Complete Declare if all smelter names have been provided in this survey response under the scope of products declared on the Declaration tab cell D57
Gold  (*) Yes Complete


1     Complete Declare if all smelter names have been provided in this survey response under the scope of products declared on the Declaration tab cell D58
Tungsten     Complete


  1   Complete Declare if all smelter names have been provided in this survey response which the scope of products declared on the Declaration tab cell D59
7) Has all applicable smelter information received by your company been reported in this declaration?  (*)      



Tantalum     Complete

  1   Complete Declare if all applicable Tantalum smelter information has been provided on Declaration tab cell D62
Tin  (*) Yes Complete

1     Complete Declare if all applicable Tin smelter information has been provided on Declaration tab cell D63
Gold  (*) Yes Complete

1     Complete Declare if all applicable Gold smelter information has been provided on Declaration tab cell D64
Tungsten     Complete

  1   Complete Declare if all applicable Tungsten smelter information has been provided on Declaration tab cell D65
Question      
A. Have you established a conflict minerals sourcing policy? (*) Yes Complete

1     Complete Answer if your company has a DRC conflict-free sourcing policy on the Declaration tab cell D69
B. Is your conflict minerals sourcing policy publicly available on your website? (Note – If yes, the user shall specify the URL in the comment field.) (*) Yes Complete

1     Complete Answer if your company has made your DRC conflict-free sourcing policy publically available on your website on the Declaration tab cell D71
The URL in the comment field www.metalsurfaces.com Complete 1     Complete Enter the URL in Declaration worksheet cell G71 if you answer "Yes" for question B. The format of the URL should be "www.companyname.com"
C. Do you require your direct suppliers to be DRC conflict-free? (*) Yes Complete

1     Complete Answer if you require your direct suppliers to be DRC conflict-free on the Declaration tab cell D73
D. Do you require your direct suppliers to source the 3TG from smelters whose due diligence practices have been validated by an independent third party audit program? (*) Yes Complete

1     Complete Answer if you require your direct suppliers to source from smelters validated as DRC conflict-free using the Conflict-Free Sourcing Inititiave compliant smelter list on Declaration tab cell D75
E. Have you implemented due diligence measures for conflict-free sourcing? (*) Yes Complete

1     Complete Answer if you have implemented conflict-free minerals sourcing due diligence measures on Declaration tab cell D77
F. Does your company conduct Conflict Minerals survey(s) of your relevant supplier(s)? (*) Yes, in conformance with IPC1755 (e.g., CMRT) Complete

1     Complete Answer if you request your suppliers to fill out this Conflict Minerals Reporting Template on Declaration tab cell D79
             
G. Do you review due diligence information received from your suppliers against your company’s expectations? (*) Yes Complete

1     Complete Answer if you verify responses from your suppliers against your company's expectations on Declaration tab cell D83
H. Does your review process include corrective action management? (*) Yes Complete

1     Complete Answer if your verification process includes corrective action management on Declaration tab cell D85
I. Is your company required to file an annual conflict minerals disclosure with the SEC? (*) No Complete

1     Complete Answer if you are subject to the SEC Disclosure requirement on Declaration tab cell D87
Product List No products or item numbers listed Complete

  1   Complete If applicable, provide 1 or more Products or Item Numbers this declaration applies to. From Declaration tab select hyperlink in cell 6H1 to enter Product List tab
Smelter List - Tantalum   Provide list of tantalum smelters contributing material to supply chain on Smelter List tab

  1   Complete Provide list of tantalum smelters contributing material to supply chain on Smelter List tab   Please answer Question 1 / Question 2 on Declaration tab
Smelter List - Tin   Complete

1     Complete Provide list of tin smelters contributing material to supply chain on Smelter List tab   Please answer Question 1 / Question 2 on Declaration tab
Smelter List - Gold   Complete

1     Complete Provide list of gold smelters contributing material to supply chain on Smelter List tab   Please answer Question 1 / Question 2 on Declaration tab
Smelter List - Tungsten   Provide list of tungsten smelters contributing material to supply chain on Smelter List tab

 [1] 1   Complete Provide list of tungsten smelters contributing material to supply chain on Smelter List tab   Please answer Question 1 / Question 2 on Declaration tab
All rows with "Smelter not listed" selected, have a name and country listed   N/A         Complete N/A   Please complete columns D & E on Smelter List for all rows "Smelter Not Listed" selected in column C

[1]
John Plyler:
change from F50 to F25 to F28