8.4 - SF 1413 Prime Contractor Acknowledgment.pdf

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438168-CC-24 RSL Room Upgrades
Solicitation number
438168-CC-24
Issued by

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This document is a Standard Form 1413 (SF 1413), which is a Statement and Acknowledgment form used in federal contracting. The prime contractor, the NNSA M&O Contracting Operations Division, awarded a subcontract on November 4, 2015 to Mission Support and Test Services LLC for the RSL Room Upgrades project located at Andrews AFB, MD. The subcontractor acknowledges that the required labor standards clauses are included in the subcontract. The related federal contract opportunity, Solicitation Number 438168-CC-24, is for the RSL Room Upgrades project, which requires the subcontractor to perform demolition, build and install a new wall, install an access door, remove and reattach surface-mounted items, and complete finishing work to modify an existing interior meeting room to meet security requirements. The Department of Energy is the federal agency issuing this solicitation.

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STATEMENT AND ACKNOWLEDGMENT OMB Control Number: 9000-0066 Expiration Date: 5/31/2025

PART I - STATEMENT OF PRIME CONTRACTOR

1. PRIME CONTRACT NUMBER 2. DATE SUBCONTRACT

AWARDED

3. SUBCONTRACT NUMBER

15b. TITLE OF PERSON SIGNING

AUTHORIZED FOR LOCAL REPRODUCTION

PREVIOUS EDITION IS NOT USABLE

STANDARD FORM 1413 (REV. 4/2013)

Prescribed by GSA/FAR (48 CFR) 53.222(e)

4. PRIME CONTRACTOR 5. SUBCONTRACTOR

a. NAME a. NAME

b. STREET ADDRESS b. STREET ADDRESS

c. CITY d. STATE e. ZIP CODE c. CITY d. STATE e. ZIP CODE

6. The prime contract does, does not contain the clause entitled "Contract Work Hours and Safety Standards Act -- Overtime Compensation."

7. The prime contractor states that under the contract shown in Item 1, a subcontract was awarded on the date shown in Item 2 to the subcontractor identified in item 5 by the following firm:

a. NAME OF AWARDING FIRM

b. DESCRIPTION OF WORK BY SUBCONTRACTOR

8. PROJECT 9. LOCATION

10a. NAME OF PERSON SIGNING 11. BY (Signature) 12. DATE SIGNED

10b. TITLE OF PERSON SIGNING

PART II - ACKNOWLEDGMENT OF SUBCONTRACTOR

13. The subcontractor acknowledges that the following clauses of the contract shown in Item 1 are included in this subcontract:

Contract Work Hours and Safety Standards Act - Overtime Compensation (If included in prime contract see Block 6) Payrolls and Basic Records Withholding of Funds Disputes Concerning Labor Standards Compliance with Construction Wage Rate Requirements and Related Regulations

Construction Wage Rate Requirements Apprentices and Trainees Compliance with Copeland Act Requirements Subcontracts (Labor Standards) Contract Termination - Debarment Certification of Eligibility

14. NAME(S) OF ANY INTERMEDIATE SUBCONTRACTORS, IF ANY

A C

B D

15a. NAME OF PERSON SIGNING 16. BY (Signature) 17. DATE SIGNED

Paperwork Reduction Act Statement - This information collection meets the requirements of 44 U.S.C. § 3507, as amended by section 2 of the Paperwork Reduction Act of 1995. You do not need to answer these questions unless we display a valid Office of Management and Budget (OMB) control number.

The OMB control number for this collection is 9000-0066. We estimate that it will take .05 hours to read the instructions, gather the facts, and answer the questions. Send only comments relating to our time estimate, including suggestions for reducing this burden, or any other aspects of this collection of information to: U.S. General Services Administration, Regulatory Secretariat Division (M1V1CB), 1800 F Street, NW, Washington, DC 20405.

EXHIBIT D, ATTACHMENT NO. 9

1 PRIME CONTRACT NUMBER: DE-NA0003624
3 SUBCONTRACT NUMBER:
a NAME: NNSA M&O Contracting Operations Division
a NAME_2:
b STREET ADDRESS: NA-APM-13, Forrestal Building, 1000 Independence Avenue, S.W.
b STREET ADDRESS_2:
c CITY: Washington
d STATE: DC
e ZIP CODE: 20585
c CITY_2:
d STATE_2:
e ZIP CODE_2:
does: On
does not contain the clause entitled Contract Work Hours and Safety Standards Act: Off
b DESCRIPTION OF WORK BY SUBCONTRACTOR: Mission Support and Test Services LLC
8 PROJECT: RSL Room Upgrades
9 LOCATION: RSL 1783 Arnold Ave., Rm 236, Andrews AFB, MD 20762
10a NAME OF PERSON SIGNING: Corrine E. Carter
10b TITLE OF PERSON SIGNING: Procurement Specialist
A:
C:
B:
D:
15a NAME OF PERSON SIGNING:
15b TITLE OF PERSON SIGNING:
Text2: Perform modifications to an existing meeting room to meet nationally mandated security requirements.
Date1_af_date: 11/04/2015
Date2_af_date:
Date3_af_date:

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