SALS Status Report Attestation

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This is Appendix B to the SALS Application Instructions and Attestation Forms.

Each step of the IDESG SALS process is a voluntary program. Identity Service Providers who choose to self-report on their progress, using this form, are not required to apply for Listed SALS Provider status. However, all persons providing information to IDESG for posting in the SALS program, on either form, are required to agree to the IDESG SALS Supplemental Terms of Use, which give IDESG the necessary permissions to maintain and re-post the contributed information.

The primary purpose of this form is to confirm that IDESG has the reporting entity's permission to re-publish the results of the entity's self-assessment (on its submitted Matrix) to the public. Accordingly, while some of the information on this Attestation may not be shared with the public (see the SALS Data Handling and Use Policy), please only provide information on the Matrix that is appropriate for wide distribution.

Please Note:
When submitted to IDESG, the Attestation must be provided on the PDF form downloadable from this page, and must be signed. All sections of the Attestation marked as mandatory by a double asterisk (" ** ") must be completed: submitted forms with information missing in those fields will be rejected.
This Web page version is provided for the convenience of readers only. The definitive current text for this document is the PDF download provided here:

DOWNLOAD LINK: Status Report Attestation (with instructions)
Saved static documents may not always represent the most current information. Applicant providers are encouraged to return to this page to obtain the most recent version of this Attestation.

Bracketed numbers ("<1>") in this Appendix are for reference, and are cross-indexed to the index numbers in the data elements list in Appendix 1 to the SALS Data Handling and Use Policy, and are not present on the PDF form provided for official submissions. Item <20> is deliberately omitted from this form.

Part 1. Reporting Entity ("Service Provider") Information

Name of Service Provider: ** <1>

Service Provider’s Physical Address: **

Street Address: <2a>
City: <2b>
State/Province: <2c>
Country: <2d>
Postal Code: <2e>

Check box if mailing address is same as physical address: ____

Mailing Address ** (If mailing address is different than business address:)

Street Address or Box: <3a>
City: <3b>
State/Province: <3c>
Country: <3d>
Postal Code: <3e>

Provider’s General Telephone: <4>

Provider Email: <5>

Provider URL:** <6>

Identity Service-specific URL to be referenced, if any: <7>

- - - - - - - -

Point of Contact ("PoC") for application information:

PoC Name: ** <8>

PoC email: ** <9>

PoC Telephone: ** <10>

- - - - - - - -

DUNS Number:** <11>

or No DUNS Number: Check box: ___

If no DUNS Number, then:

Jurisdiction of Registration or Legal Formation (State/Locality): ** <12a>
Date of Registration or Legal Formation: ** <12a>
Government-assigned Registration, Incorporation, or Business License Number: <12c>

- - - - - - - -

Applicant Service Description: (at applicant's option, for inclusion in any listing: 200 Word Limit) <13>

- - - - - - - -

Please provide any needed explanations regarding unavailable information here:

- - - - - - - -

Part 2. Assessed Services:

Applicant provides the following types of identity management activities or services assessed in this report:

** Check all that apply
a. Registration __ <14a>
b. Credentialing __ <14b>
c. Authentication __ <14c>
d. Authorization __ <14d>

(See the IDEF_Glossary DIGITAL IDENTITY MANAGEMENT FUNCTIONS for more information on each function.)

Part 3. Self-Assessment Information

Self-Assessor Name:** <15>

Self-Assessor Title:** <16>

Email:** <17>

Telephone: ** <18>

Part 4. Self-Assessment Report Date

Assessment Completion Date:** <19>

Please note: This must match the date on the Self-Assessment Matrix. (This is the date "as of" which your information will be reported to be current. Information submitted in the application must be current as of this date.

A completed Self-Assessment Matrix MUST be attached to or delivered with this form, in order to make a valid complete submission.

Part 5. Agreement

I confirm as of the date indicated below that the information provided on this IDESG Status Report Attestation, and the Self-Assessment Matrix delivered with it, regarding our organization's progress in implementing the Baseline Requirements, correctly reflects the results of the Applicant's self-assessment to date, for the services indicated above. However, these results are reported for general information only, and do not create any warranty or liability to any other party.

My signature on this document indicates my acknowledgment that the SALS Supplemental Terms of Use apply to this information and submission, and that I have been authorized by the organization named below to submit that information and agree to these terms.

Signature: __<21>________________________________

Name (in text)_<22>________________________________

Position/Title: __<23>_____________________________


On behalf of: __<1>_______________________________ (Insert name of "Provider" here)

>> Forward to: Appendix A: SALS Full Compliance Attestation Form
<< Back to: SALS Application Instructions and Attestation Forms
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