03 Work Sample Cover Sheet.docx

SOLICITATION H9240022R0008

ATTACHMENT 03

WORK SAMPLE COVER SHEET

PART I: WORK SAMPLE IDENTIFICATION

Contractor Name:

Contract Number:

Order Number (if applicable)

Customer (Agency/Organization):

Total Period of Performance, Including Options: (MM/YYYY – MM/YYYY or MM/YYYY – Present)

Work Sample Value:

Task Order against a Multiple Award Federal Government Contract (Yes/No)

Funding Agency ID

Was this work sample performed as the Prime Contractor (Yes/No)

PART IIa: WORK SAMPLE INFORMATION/POINTS OF CONTACT (If work sample is as the Prime Contractor) Contracting Officer

NAME:

TITLE:

AGENCY or CUSTOMER:

PHONE:

E-MAIL:

Contracting Officer’s Representative or Other Government Representative

NAME:

TITLE:

AGENCY or CUSTOMER:

PHONE:

E-MAIL:

Contracting Officer’s Representative or Other Government Representative

NAME:

TITLE:

AGENCY or CUSTOMER:

PHONE:

E-MAIL:

PART IIb: WORK SAMPLE INFORMATION/POINTS OF CONTACT (If work sample is as the Sub Contractor)

NAME:

TITLE:

COMPANY:

PHONE:

E-MAIL:

PART III: PROJECT DESCRIPTION (900 Character Limit)

PART IV: WORK SAMPLE VERIFICATION METHOD (OPTIONAL)

Signature below by reference identified in Part II

Signature below by a Contracting Officer, Contracting Officer’s Representative, Other Government Representative for the ordering activity constitutes acceptance of the above project information to be accurate as ordered and received by the listed entity

Name:

Date:

Signature:

PART I: WORK SAMPLE IDENTIFICATION

Contractor Name: Enter the Contractor’s Name of this work sample.

Contract Number: Enter the Contract Number.

Order Number: Enter the Task Order Number if applicable.

Customer: Enter the Office Symbol and Program Name this work sample supports.

TOTAL PERIOD OF PERFORMANCE, INCLUDING OPTIONS: (MM/YYYY – MM/YYYY or MM/YYYY

– Present):

Work Sample Value: Enter the final or most recent total contract value of the work sample. Task Order Against A Multiple Award Federal Government Contract: Select Yes or No Funding Agency ID: Enter the Funding Agency ID utilized for the Work Sample.

Was this Work Sample Performed as the Prime Contractor? Select Yes if the Contractor listed under Contractor Name was the Prime under the Work Sample.

PART IIa: WORK SAMPLE INFORMATION/POINTS OF CONTACT (If Offeror was the Prime Contractor for the work sample) Contracting Officer: Provide the contact information for either the current Contracting Officer working the contract or the most recent Contracting Officer if the contract has ended. If there is no available Contracting Officer then leave this section blank.

Contracting Officer’s Representative or Other Government Representative: Provide the contact information for the Primary (or Alternate if Primary is not available) COR or if a COR is not available a Government Representative that would be able to assist in validation of the work sample.

Each Offeror shall provide at least two (2) Points of Contact (POCs) for each Work Sample.

PART IIb: WORK SAMPLE INFORMATION/POINTS OF CONTACT (If Offeror was a Subcontractor for the work sample) Provide the contact information for either the current Contract Administrator working the contract or the most recent Contract Administrator if the contract has ended. If there is no available Contract Administrator, then leave this section blank.

PART III: WORK SAMPLE DESCRIPTION (900 Character Limit) This space is provided to allow the Offeror to present a brief synopsis of the work sample. The information provided will not be evaluated.

PART IV: WORK SAMPLE VERIFICATION METHOD (OPTIONAL)

After completing Parts I-III, Offerors are encouraged to provide the worksheet to the POCs listed under Parts II and III. The POCs should review the provided information from the Work Sample Cover Sheet, and only the Work Sample Cover Sheet. Their signature will constitute verification that the information provided is accurate. If a POC is not available to sign the Cover Sheet the requested form of verification is to provide the most recent FPDS report for the contract. Part IV is optional but recommended to provide advance notice to the POCs that they may be contacted to support validation of the Work Sample.