36C10G19R0008-011.docx

PAGE 1 OF

1. REQUISITION NO.

2. CONTRACT NO.

3. AWARD/EFFECTIVE DATE

4. ORDER NO.

5. SOLICITATION NUMBER

6. SOLICITATION ISSUE DATE

a. NAME

b. TELEPHONE NO. (No Collect Calls)

8. OFFER DUE DATE/LOCAL

TIME

9. ISSUED BY

CODE

10. THIS ACQUISITION IS

UNRESTRICTED OR

SET ASIDE:

% FOR:

SMALL BUSINESS

HUBZONE SMALL

BUSINESS

SERVICE-DISABLED

VETERAN-OWNED

SMALL BUSINESS

WOMEN-OWNED SMALL BUSINESS

(WOSB) ELIGIBLE UNDER THE WOMEN-OWNED

SMALL BUSINESS PROGRAM

EDWOSB

8(A)

NAICS:

SIZE STANDARD:

11. DELIVERY FOR FOB DESTINA-

TION UNLESS BLOCK IS

MARKED

SEE SCHEDULE

12. DISCOUNT TERMS

13a. THIS CONTRACT IS A

RATED ORDER UNDER

DPAS (15 CFR 700)

13b. RATING

14. METHOD OF SOLICITATION

RFQ

IFB

RFP

15. DELIVER TO

CODE

16. ADMINISTERED BY

CODE

17a. CONTRACTOR/OFFEROR

CODE

FACILITY CODE

18a. PAYMENT WILL BE MADE BY

CODE

TELEPHONE NO.

DUNS:

DUNS+4:

PHONE:

FAX:

17b. CHECK IF REMITTANCE IS DIFFERENT AND PUT SUCH ADDRESS IN OFFER 18b. SUBMIT INVOICES TO ADDRESS SHOWN IN BLOCK 18a UNLESS BLOCK BELOW IS CHECKED

SEE ADDENDUM

19.

20.

21.

22.

23.

24.

ITEM NO.

SCHEDULE OF SUPPLIES/SERVICES

QUANTITY

UNIT

UNIT PRICE

AMOUNT

(Use Reverse and/or Attach Additional Sheets as Necessary)

25. ACCOUNTING AND APPROPRIATION DATA

26. TOTAL AWARD AMOUNT (For Govt. Use Only) 27a. SOLICITATION INCORPORATES BY REFERENCE FAR 52.212-1, 52.212-4. FAR 52.212-3 AND 52.212-5 ARE ATTACHED. ADDENDA

ARE

ARE NOT ATTACHED.

27b. CONTRACT/PURCHASE ORDER INCORPORATES BY REFERENCE FAR 52.212-4. FAR 52.212-5 IS ATTACHED. ADDENDA

ARE

ARE NOT ATTACHED

28. CONTRACTOR IS REQUIRED TO SIGN THIS DOCUMENT AND RETURN _______________

29. AWARD OF CONTRACT: REF. ___________________________________ OFFER

COPIES TO ISSUING OFFICE. CONTRACTOR AGREES TO FURNISH AND

DATED ________________________________. YOUR OFFER ON SOLICITATION

DELIVER ALL ITEMS SET FORTH OR OTHERWISE IDENTIFIED ABOVE AND ON ANY

(BLOCK 5), INCLUDING ANY ADDITIONS OR CHANGES WHICH ARE

ADDITIONAL SHEETS SUBJECT TO THE TERMS AND CONDITIONS SPECIFIED

SET FORTH HEREIN IS ACCEPTED AS TO ITEMS:

30a. SIGNATURE OF OFFEROR/CONTRACTOR 31a. UNITED STATES OF AMERICA (SIGNATURE OF CONTRACTING OFFICER) 30b. NAME AND TITLE OF SIGNER (TYPE OR PRINT) 30c. DATE SIGNED 31b. NAME OF CONTRACTING OFFICER (TYPE OR PRINT) 31c. DATE SIGNED

AUTHORIZED FOR LOCAL REPRODUCTION

(REV. 2/2012)

PREVIOUS EDITION IS NOT USABLE

Prescribed by GSA - FAR (48 CFR) 53.212

7. FOR SOLICITATION

INFORMATION CALL:

STANDARD FORM 1449

OFFEROR TO COMPLETE BLOCKS 12, 17, 23, 24, & 30

SOLICITATION/CONTRACT/ORDER FOR COMMERCIAL ITEMS

TBD

VA119-19-J-EXAMPLE

John Tarver 540-735-3850

36C10G U.S. Department of Veterans Affairs Strategic Acquisition Center 10300 Spotsylvania Ave

Fredericksburg VA 22408

X

339113

N/A

To Be Determined

36C10G

Strategic Acquisition Center 10300 Spotsylvania Ave

Fredericksburg VA 22408

313-410-547

Financial Services Center

PO BOX 149971

Austin TX 78714-8917

This is a Firm Fixed Price (FFP) Delivery Order issued against IDIQ contract TBD for Cardiac Implants.

The period of performance for this delivery order

TBD

All applicable terms and conditions are in agreement with IDIQ contract TBD unless otherwise addressed in the Delivery Order.

THIS DRAFT IS FOR EXAMPLE ONLY. THIS IS NOT AN OFFICIAL TASK ORDER TO BE USED FOR PRICING EVALUATION ONLY.

x x X

Lawrence B. Toperoff CO, Division 5B

Table of Contents

CONTINUATION PAGE

A.2 PRICE/COST SCHEDULE

ITEM INFORMATION

Electric Bed w/Rails (no mattress) (E0266)*

Electric Bed only (no rails or mattress)(E0297)*

Foam Pressure Reduction Mattress only (E0184)*

Full Rail (E0310)*

Half Rail (E0305)*

Split Rails (Combination of 2 half rails (E0305)*

Trapeze, bed mounted (E0910)*

10,472.00

5056.00

13,368.00

2,041.00

4,295.00

2,147.00

4,998.00

EA

EA

GRAND TOTAL

*The Healthcare Common Procedure Coding System (HCPCS).

ACCOUNTING AND APPROPRIATION DATA

SECTION B

B.1 Contract Administration

1. All contract administration matters will be handled by the following individuals:

a. CONTRACTOR: TBD

b. GOVERNMENT:

U.S. Department of Veteran Affairs Strategic Acquisition Center 10300 Spotsylvania Ave Suite 400 Fredericksburg, VA 22408

2. CONTRACTOR REMITTANCE ADDRESS: All payments by the Government to the contractor will be made in accordance with:

[X] 52.232-33, Payment by Electronic Funds Transfer-- System for Award Management (July 2013)

[X] 52.232-36, Payment by Third Party

3. INVOICES: Invoices shall be submitted in arrears:

4. GOVERNMENT INVOICE ADDRESS: All invoices from the contractor shall be submitted as follows:

FSC e-INVOICE PROGRAM THRU AUSTIN PORTAL/FSC MANDATORY ELECTRONIC INVOICE SUBMISSION FOR AUSTIN PAYMENTS

Vendor e-invoice Set-up information:

Tungsten/OB10 electronic invoicing is free to all VA vendors. In order to submit electronic invoices, all VA vendors must register with Tungsten/OB10 by logging on to http://www.tungsten-network.com/media/47595/ob10_howto_register_13_v3.pdf and following the registration instructions or calling 1-877-489-6135 for Enrollment.

In addition to invoice requirements stated in FAR 52.212-4, all invoices MUST include the following:

1. Name, Address and Phone Number of the Contractor

1. Invoice date, Invoice Number and Payment Terms

1. The Purchase Order Number TBD: Item number, description, quantity, unit of measure, price, extended price (as stated in the Purchase Order / Contract / Modification / Task Order) and a total of supplies delivered or services performed.

1. Cumulative billing (per line item and total).

1. Final invoices must be marked “FINAL INVOICE”.

1. Proof of supplies delivered or services performed MUST also be provided.

1. Signature, printed name and title of Government Receiving Official and date of delivery or performance period must be included.

INVOICES THAT DO NOT COMPLY WITH THESE REQUIREMENTS WILL BE REJECTED.

For questions regarding invoice receipt or payment, please call VAFSC directly at 1-877-353-9791 or email vafsccshd@va.gov.

5. GOVERNMENT CONTRACTING OFFICER REPRESENTATIVE (COR) OR OTHER DESIGNATED POINT OF CONTACT:

The COR will be designated with a COR appointment letter.