Attachment_6_- CR_Invoice_Form.docx

Attachment 6 - FDA TOBACCO INSPECTION INVOICE A. Expenditure Category*

B. Negotiated Amounts for This Performance Period

C. Current Amounts Billed

D. Previous Amounts Billed

E. Cumulative Amounts Billed

F. Total Contract Value

(n) Direct Costs:

(1) Direct Labor

(2) Fringe Benefits ( %)

(3) Accountable Property

(4) Materials & Supplies

(5) Premium Pay

(6) Consultant Fees

(7) Travel

(8) Subcontracts

(9) Other

Total Direct Costs

(o) Indirect Costs ( %)

(p) Fixed Fee ( %)

(q) Total Amount Claimed

(r) Adjustments

(s) Grand Totals

(a) Designated Billing Office Name and Address:

(b) Contractor’s Name, Address, Point of Contact, TIN, and DUNS or DUNS+4 Number

POC: TIN:

DUNS or DUNS+4: (c) Date Invoice Prepared:

(d) Invoice Number:

Tobacco-last 4 digits Contract #-MM-YYYY-invoice #

(e) Contract No.: (f) Contract Title: (g) Effective Date: (h) Total Estimated Cost of Contract: $ (i) Total Fixed Fee (if applicable): (j) Office of Acquisitions:

“I certify that all payments requested are for appropriate purposes and in accordance with the contract.”

_ [Name] [Title]

PLEASE DO NOT USE THE SPACE BELOW

Payment of this invoice in the amount of $ is recommended. Currently, required reports and deliverables have been received.

Contracting Officer Date

OAGS

*Attach details as specified in the contract or requested by the Contracting Officer

INVOICE INSTRUCTIONS FOR

FDA TOBACCO INSPECTION COST-REIMBURSEMENT CONTRACTS

Format: Submit payment requests on the FDA Tobacco Inspection invoice form in the manner and format prescribed herein and as illustrated in the Sample Invoice. Standard Form 1034, Public Voucher for Purchases and Services Other Than Personal, may be used in lieu of this form provided it contains all of the information shown on the Sample Invoice. DO NOT include a cover letter with the payment request.

Submission Format: Submissions via e-mail are preferred. The Contractor shall submit invoices to FDAVendorPaymentsTeam@fda.hhs.gov. All supporting documentation shall also be submitted.

Frequency: Payment requests shall be submitted quarterly unless otherwise agreed.

Cost Incurrence Period: Costs incurred must be within the contract performance period or covered by precontract cost provisions.

Billing of Costs Incurred: If billed costs include (1) costs of a prior billing period, but not previously billed, or (2) costs incurred during the contract period and claimed after the contract period has expired, the Contractor shall site the amount(s) and month(s) in which the costs were incurred.

Contractor's Fiscal Year: Prepare payment requests in such a manner that the Government can identify costs claimed with the Contractor's fiscal year.

Currency: All contracts are expressed in United States dollars.

Costs Requiring Prior Approval: Identify and reference the Contracting Officer's Authorization (COA) Number for costs requiring the Contracting Officer's approval, which are not set forth in an Advance Understanding in the contract. In addition, the Contractor shall show any cost set forth in an Advance Understanding as a separate entry under the appropriate expenditure category on the payment request.

Invoice Identification: Identify each payment request as either:

1) Interim Invoice: These are interim payment requests submitted during the contract performance period.

2) Completion Invoice: Submit the completion invoice promptly upon completion of the work, but no later than one year from the contract completion date, or within 120 days after settlement of the final indirect cost rates covering the year in which the contract is physically complete (whichever date is later). The Contractor shall submit the completion invoice when all costs have been assigned to the contract and all performance provisions have been completed.

3) Final Invoice: A final invoice may be required after the amounts owed have been settled between the Government and the Contractor (e.g., resolution of all suspensions and audit exceptions).

Preparation and Itemization of the Invoice: The Contractor shall furnish the information set forth in the instructions below. The instructions are keyed to the entries on the Sample Invoice/Financing Request. All information must be legible or the invoice will be considered improper and returned to the Contractor.

(a) Designated Billing Office Name and Address: Enter the designated billing office name and address, as identified in the Invoice Submission Instructions in Section G of the Contract Schedule.

(b) Contractor's Name, Address, Point of Contact, TIN, and DUNS or DUNS+4 Number: Show the Contractor's name and address exactly as they appear in the contract. Also include the name, title, phone number, and e-mail address of the Point of Contact (POC) in case of questions. Any invoice identified as improper will be returned to the POC identified. If the remittance name differs from the legal business name, both names must appear on the invoice. Provide the Contractor's Federal Taxpayer Identification Number (TIN) and Data Universal Numbering System (DUNS) or DUNS+4 number. The DUNS number must identify the Contractor's name and address exactly as stated in the contract, and as registered in the System for Award Management (SAM) at www.sam.gov. Registration is SAM has replaced registering with the Central Contractor Registration (CCR) database. If a Contractor was registered in CCR, it must ensure that its information was properly transferred from CCR to SAM.

When an approved assignment of claims has been executed, the Contractor shall provide the same information for the assignee as is required for the Contractor (i.e., name, address, point of contact, TIN, and DUNS number), with the remittance information clearly identified as such.

(c) Date Invoice Prepared: Insert the date the payment request is prepared.

(d) Invoice Number: Identify each payment request by a unique invoice number, which can only be used one time regardless of the number of contracts or orders held by an organization. For example, if a contractor has already submitted invoice number 05 on one of its contracts or orders, it cannot use that same invoice number on any other contract or order. Payment requests with duplicate invoice numbers will be considered improper and returned to the contractor.

For these reasons, it is recommended that the Contractor use the number format provided (Tobacco-####-MM-YYYY-####), but this format is not mandatory. Invoice numbers are limited to 30 characters. There are no restrictions on the use of special characters, such as colons, dashes, forward slashes, or parentheses. If all or part of an invoice is suspended and the contractor chooses to reclaim those costs on a supplemental invoice, the contractor may use the same unique invoice number followed by an alpha character, such as "R" for revised (example: Tobacco-221C-01-2013-0001R).

(e) Contract Number: Insert the contract number as it appears on the contract.

(f) Contract Title: Insert the contract title listed on the cover page of the contract.

(g) Effective Date: Insert the first day of the period of performance.

(h) Total Estimated Cost of Contract: Insert the total estimated cost of the contract. For contracts/orders with options or incremental funding provisions, enter the amount currently obligated and available for payment.

(i) Total Fixed-Fee: Insert the total fixed-fee (where applicable). For contracts/orders with options or incremental funding provisions, enter the amount currently obligated and available for payment (where applicable).

(j) Office of Acquisitions: Insert the name of the Office of Acquisitions, as identified in the Invoice Submission Instructions in Section G of the Contract Schedule.

(k) Bank Information: Insert the bank name, address, routing number and account number where payments should be deposited. Please ensure this information matches what is registered in (SAM) at www.sam.gov.

(l) Billing Period: Insert the beginning and ending dates (month, day, and year) of the period in which costs were incurred and for which reimbursement is claimed.

Columns A. Expenditure Category: These should correspond to approved line items in your business proposal. Each expenditure for which the contractor is seeking reimbursement should include supporting documentation. Supporting documentation should include a separate breakdown of the specific line items such as each employee or each item. This breakdown should include a description of the number of hours proposed, number of hours worked, rate, and total; or price of each item, quantity each item, and total cost for similar items. Supporting documentation will also include corresponding timesheets or payroll figures and receipts.

B. Negotiated Amounts for This Performance Period: These values should correspond to the amounts agreed upon for each expenditure during the current period of performance. If the billing period includes the base year of the contract, the base year is the current period of performance. If the billing period covers one of the option years under the contract, that option year is the current period of performance.

C. Current Amounts Billed: Insert the amount claimed for the current billing period by major costs element. This should include costs incurred between the dates listed in (l).

D. Previous Amounts Billed: Insert the amount previously billed for each cost element during the course of this contract, not including the current amounts billed. If the billing period covers an option year, the amounts should include costs billed during the base year and any previous option years.

E. Cumulative Amounts Billed: Insert the total amounts billed under the current contract, including the base year and all option years. This should equal the Current Amounts Billed and Previous Amounts Billed.

F. Total Contract Value: Insert the total amount obligated to this contract for each cost element. If the billing period includes an option year, include the option year, any previous option years, and the base year.

(m) Contract Line Item Number (CLIN) – Insert CLIN number for contract period of performance as indicated in the contract.

(n) Direct Costs: Insert the major cost elements. For each element, consider the application of the paragraph entitled "Costs Requiring Prior Approval" on page 1 of these instructions. Attach supporting documentation that explicitly explains the hours and wages for each employee or the specific costs for each item.

1) Direct Labor: Include salaries and wages paid (or accrued) for direct performance of the contract

2) Fringe Benefits: List any fringe benefits applicable to direct labor and billed as a direct cost. Cite the rate(s) used to calculate fringe benefit costs, if applicable

3) Accountable Personal Property: Include permanent research equipment and general purpose equipment having a unit acquisition cost of $1,000 or more, with a life expectancy of more than two years, and sensitive property regardless of cost (see the HHS Contractor's Guide for Control of Government Property).

Show permanent research equipment separate from general purpose equipment. On a separate sheet of paper attached to the payment request, list each item for which reimbursement is requested: Precede the item with an asterisk(*) if the equipment is below the $1,000 approval level. Include reference to the following (as applicable):

i. item number for the specific piece of equipment listed in the Property Schedule, and ii. COA number, if the equipment is not covered by the Property Schedule.

The Contracting Officer may require the Contractor to provide further itemization of property having specific limitations set forth in the contract

4) Materials and Supplies: Include equipment with unit costs of less than $1,000 or an expected service life of two years or less, and consumable material and supplies regardless of amount.

5) Premium Pay: List remuneration in excess of the basic hourly rate.

6) Consultant Fee: List fees paid to consultants. Identify consultant by name or category as set forth in the contract or COA, as well as the effort (i.e., number of hours, days, etc.) and rate billed.

7) Travel: Include domestic and foreign travel. Foreign travel is travel outside of Canada, the United States and its territories and possessions. However, for an organization located outside Canada, the United States and its territories and possessions, foreign travel means travel outside that country. Foreign travel must be billed separately from domestic travel.

8) Subcontract Costs: List subcontractor(s) by name and amount billed.

9) Other: List all other direct costs in total unless exceeding $1,000 in amount. If over $1,000, list cost elements and dollar amounts separately. If the contract contains restrictions on any cost element that cost element must be listed separately.

(o) Indirect Costs: Identify the indirect cost base, indirect cost rate, and amount billed for each indirect cost category.

(p) Fixed-Fee: Cite the formula or method of computation for fixed-fee, if applicable. The fixed-fee must be claimed as provided for by the contract. Most FDA State Tobacco Inspection Contracts will not have this cost.

(q) Total Amounts Claimed: Insert the total amounts claimed for the current and cumulative.

(r) Adjustments: Include amounts conceded by the Contractor, outstanding suspensions, and/or disapprovals subject to appeal.

(s) Grand Totals

The Contractor’s submitting official must sign the payment request certifying that all payments requested are for appropriate purposes and in accordance with the contract.

The Contracting Officer may require the Contractor to submit detailed support for costs claimed on one or more interim payment requests.