Technical_Exhibit_F_-_DHS_700-01_Cumulative_Claim_and_Reconciliation_Statement.pdf

DEPARTMENT OF HOMELAND SECURITY

CUMULATIVE CLAIM AND RECONCILIATION STATEMENT

OMB Control No:1600-0002 Expiration Date 06/30/2018

PRA Burden Statement: This collection of information is mandatory and will be used to fulfill the requirements of the Homeland Security Acquisition Regulation (HSAR). Public reporting burden is estimated to average 1 hour 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 this burden, to the Office of the Chief Procurement Officer, Acquisitions Policy and Legislation, Department of Homeland Security, Washington, DC 20528. Please note that an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this collection is 1600-0002 and it expires 06/30/2018.

1. Name of Contractor

2. Address of Contractor

3. Contract No. 4. Delivery/Task Order No.

5. The total amount claimed under the above numbered contract, delivery order, or task order is as follows:

a. Direct Labor $

b. Direct Material $

c. Other Direct Costs $

d. Overhead $

e. G&A $

f. Subcontract Cost $

g. Total Costs (5a through 5f) $

h. Fixed Fee $

i. Other Fee $

j. Total Amount Claimed $

6. Total amount due under the above numbered contract, delivery order, task order is as follows:

a. Total Amount Claimed $ b.

Total Amount Paid by the Government under Voucher Nos. $

c. Total Amount (if any) Withheld, Disallowed, etc.

(as explained on the attached sheet) $

d. Total Amount Due $

I, , as the (Full Name) of the above named contractor, declare that the above statements are correct in accordance with the records of the contractor.

(Signature)

DHS Form 700-1 (12/07) Authorized for Local Reproduction

(Title)

Thru

Cumulative Claim and Reconciliation Statement, December 2007 U.S. Department of Homeland Security, Acquisition Policy and Legislation D:20050114153406- 05'00' D:20050922171107- 04'00'

DEPARTMENT OF HOMELAND SECURITY

CUMULATIVE CLAIM AND RECONCILIATION STATEMENT

OMB Control No:1600-0002 Expiration Date 06/30/2018 PRA Burden Statement: This collection of information is mandatory and will be used to fulfill the requirements of the Homeland Security Acquisition Regulation (HSAR). Public reporting burden is estimated to average 1 hour 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 this burden, to the Office of the Chief Procurement Officer, Acquisitions Policy and Legislation, Department of Homeland Security, Washington, DC 20528. Please note that an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this collection is 1600-0002 and it expires 06/30/2018.

1. Name of Contractor

2. Address of Contractor

3. Contract No.

4. Delivery/Task Order No.

5. The total amount claimed under the above numbered contract, delivery order, or task order is as follows:

a.

Direct Labor b.

Direct Material c.

Other Direct Costs d.

Overhead e.

G&A f.

Subcontract Cost g.

Total Costs (5a through 5f) h.

Fixed Fee i.

Other Fee j.

Total Amount Claimed

6. Total amount due under the above numbered contract, delivery order, task order is as follows:

a.

Total Amount Claimed b.

Total Amount Paid by the Government under Voucher Nos.

c.

Total Amount (if any) Withheld, Disallowed, etc.

(as explained on the attached sheet) d.

Total Amount Due I, , as the (Full Name) of the above named contractor, declare that the above statements are correct in accordance with the records of the contractor.

(Signature) DHS Form 700-1 (12/07) Authorized for Local Reproduction (Title) Thru