1048V100-00153-AA - LOAD TEST CERT OF COMPLIANCE CDRL DI-MISC-81356.pdf

CONTRACT DATA REQUIREMENTS LIST

(1 Data Item)

Form Approved

OMB No. 0704-0188

Public reporting burden for this collection of information is estimated to average 110 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing the burden, to Department of Defense, Washington Headquarters Services, Directorate for Information Operations and Reports (0704-0188), 1215 Jefferson Davis Highway, Suite 1204, Arlington VA 22202-4302.

Please DO NOT RETURN your form to either of these address. Send completed form to the Government issuing Contracting Officer for the Contract/PR No. Listed in Block E.

A. CONTRACT LINE ITEM NO. B. EXHIBIT C. CATEGORY

TBD A

TDP _______________ TM _____________ Other MISC

D. SYSTEM/ITEM

FY-2021 HIC PURCHASE

E. CONTRACT/PR NO.

TBD

F. CONTRACTOR

TBD

1. DATA ITEM NO.

A007

2. TITLE OF DATA ITEM

CERTIFICATE OF COMPLIANCE

3. SUBTITLE

LOAD TEST COMPLIANCE

4. AUTHORITY (Data Acquisition Document No.)

DI-MISC-81356A

5. CONTRACT REFERENCE

SOW PARAGRAPH 4.3.4.3-7

6. REQUIRING OFFICE

PSNS & IMF C/2305.3

7. DD 250 REQ

DD

9. DIST STATEMENT

REQUIRED

D*

10. FREQUENCY

OTIME

12. DATE OF FIRST

SUBMISSION

ASREQ*

14. DISTRIBUTION

b. COPIES

8. APP CODE

N/A

11. AS OF DATE

N/A

13. DATE OF SUBSEQUENT

SUBMISSION

SEE BLOCK 16*

A. ADDRESSEE

Final

Draft Reg Repr o

16. REMARKS

Block 9: Distribution Statement D. Distribution authorized to DoD and DoD contractors only. Administration and operations only, effective 7/14/2021. Other U.S. requests shall be referred to COMNAVSEASYSCOM.

Block 12 – Certification/Data Report documentation shall be submitted via Wide Area Workflow (WAWF) e-Business Suite: Invoice, Receipt, Acceptance, and Property Transfer (iRAPT). iRAPT email notification shall be sent to:

PSNS.WAWFQACertifications.FCM@navy.mil upon submission.

Block 13- Certification/Date Report documentation shall also be submitted with the shipment of the material to the delivery address supplied:

CERTIFICATE OF COMPLIANCE DOCUMENTATION SHALL ALSO BE SUBMITTED

WITH THE SHIPMENT OF THE MATERIAL TO THE DELIVERY ADDRESS SUPPLIED:

RECEIVING OFFICER BLDG 514, ATTN: CODE C/2305

PUGET SOUND NAVAL SHIPYARD & INTERMEDIATE MAINTENACE FACILITY

1400 FARRAGUT AVE, BREMERTON, WA 98314-5001

PSNS & IMF

C/2305*

0 1 0

PSNS & IMF* 0 1 0

TOTAL 0 2 0

G. PREPARED BY H. DATE I. APPROVED BY J. DATE

/s/ Peter J. Morgan, C/980 S.2

7/14/2021 /s/ Richard J. Balter C/980 S.2

7/14/2021

DD Form 1423-1, JUN 90 Page 1 of 2 Page(s)

S/N 0102-LF-010-5600

For Document no: 1048-V100 / JO# 69M44-HICMN-S01 / Item# 800

17. PRICE GROUP

18. ESTIMATED

TOTAL PRICE

DATA ITEM DESCRIPTION

Title: Certificate of Compliance

Number DI-MISC-81356A Approval Date: 20071218

AMSC Number: N9036 Limitation: N/A

DTIC Applicable: No GIDEP Applicable: No

Office of Primary Responsibility: NAVICP Code 8741

Applicable Forms: N/A

Use/Relationship: The Certificate of Compliance provides certification from the contractor that the materiel supplied is in full compliance with all contract requirements. This DID contains the format, content, and intended use information for the data deliverable required by the contract.

This DID supersedes DI-MISC-81356.

Requirements:

1. Format. The Certificate of Compliance shall be presented in a format similar to that of

Figure 1.

2. Content. The Certificate of Compliance shall contain:

a. Contractor’s name.

b. Contractor’s address.

c. Contractor’s phone number.

d. Date.

e. Contracting Agency’s name.

f. Contract Number.

g. National Stock Number (NSN).

h. Item nomenclature.

i. A statement certifying that all items furnished on the contract are in full compliance with all specification and contract requirements.

j. Authorized personnel’s signature.

k. Authorized personnel’s printed name and title.

Source: https://assist.dla.mil -- Downloaded: 2017-10-18T14:10Z Check the source to verify that this is the current version before use.

DI-MISC-81356A

From: ______________________

(Contractor’s name)

Address: ______________________

(Contractor’s address)

Phone Number: ________________

(Contractor’s phone number)

Date: ________________

To: _______________

(Contracting Agency)

Contract Number: _______________

National Stock Number: _______________

Item Nomenclature: ___________________

“All items furnished on this contract are in full compliance with all specification and contract requirements.”

(Signature of Authorized Personnel

(Printed Name and Title of Authorized Personnel)

Note: The recording of false, fictitious, or fraudulent statements or entries on this document may be punished as a felony under Federal Statutes.

3. End of DI-MISC-81356A