Attachment 17-DHS Form 1501 Updated - 10.29.22.pdf

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Page of DHS Form 1501 (10/22) This document supersedes all previously published Purchase Card Worksheets; Please update your files accordingly.

26.

Unit of Issue 22.

Item #

2. Cardholder Telephone Number:

1. Name of Cardholder:

10. Ship To Address:

14. Vendor Name:

17. Vendor Address:

21. Detailed Justification for Purchase:

23.

Item Description

15. Vendor POC:

12. State:

16. Vendor Phone Number:

19. State:

18. City:

DEPARTMENT OF HOMELAND SECURITY

PURCHASE CARD TRANSACTION WORKSHEET

7. Requestor Phone Number:

3. Cardholder Email Address:

8. Date of Request:

11. City:

4. Component:

9. Document ID Number:

5. Program/Office:

6. Requestor Name:

13. Zip Code:

20. Zip Code:

25.

Quantity 27.

Unit Price 28.

Subtotals 29.

Date Received 24.

Stock Number

38. PROPERTY CUSTODIAN INFORMATION (Property Accountability)

37. ALL THE ABOVE ITEMS HAVE BEEN RECEIVED AND ACCEPTED (Signature must be Government Employee and cannot be the Funding Official, Approving Official, or Cardholder.)

36. PURCHASE CARDHOLDER INFORMATION (This signature cannot be Funding Official, Approving Official, or Receiver.)

35. APPROVING OFFICIAL/ALTERNATE APPROVING OFFICIAL INFORMATION (Signature cannot be Funding Official, Cardholder, or Receiver.)

34. FUNDS VERIFICATION OFFICIAL INFORMATION Note: Attach all documents BEFORE signing

39. LOCAL USE SIGNATURES (If needed)

ACCS

30. Accounting Data:

32. ESTIMATED ORDER TOTAL:

31. Purchase Log ID:

33. TO REQUIRED SOURCES for SUPPLIES to:

TO REQUIRED SOURCES for SERVICES to:

TO SPECIAL APPROVALS NEEDED

1. Agency Inventories

2. Excess from other agencies

3. Federal Prison Industries

5. Wholesale Supply Sources

4. Ability One

1. Ability One

2. Commercial

1. IT Request

3. Branding

5. OGC-Awards

4. Legal

2. Printing

6. Commercial

6. Accountable Property

7. Training

8. Other The following guidance should be used to complete the Purchase Card Worksheet. This worksheet provides a consolidated source for documenting and tracking purchase card requirements as established by applicable laws, regulations, and guidance. You must retain this form and all supporting documents in a central location for auditing purposes. This worksheet, along with the applicable documentation, should be submitted to the Component's Organization Program Coordinator for review during the Post Payment Audit process. Please contact the Component's primary organization program coordinator for any questions.

Purchase Card Worksheet Guidance Field Guidance Name of the actual cardholder making the purchase.

Phone number of the cardholder.

Email address of the cardholder.

Component where the cardholder works.

Physical location where the cardholder works.

Name of person requesting the supplies/services.

Phone number of person requesting the supplies/services.

Date the requestor submits the request.

N/A - Count function only.

Number of items requested.

The date the item was actually received.

Calculated field no input required if filling out in excel. If written then the unit price times the quantity.

Use as a check list to make sure you are looking at required sources in the proper sequence. If you are unable to satisfy requirements for supplies and services from the required sources listing then you are encouraged to consider satisfying requirements through other sources. Please note: Commercial includes but is not limited to GSA/FSS, DHS BPAs, or Federal Supply Schedules options. Special approval is required for all computer related purchases (Hardware, Software, Services).

Required for all items that require accountability.

These blocks can be used to put in any locally required approvals if needed. Some offices require some internal approvals based on total cost, prior to the purchase being made. If none are required for your office, you can remove them from the PCTW.

Signature and date of person authorized to validate funds availability. Date must be PRIOR to the purchase being made. Can be an email if official is not physically available to sign prior to the purchase.

Note: This signature cannot be the Cardholder, Approving Official, or Receiver of the purchase.

The cardholders approving official (that is set up in the bank system) signs and dates PRIOR to the purchase being made. Typed name may be prepopulated by the cardholder. It can be an email from the approving official if they are not physically available to sign prior to the purchase.

Note: This signature cannot be the Cardholder, Funding Official, or Receiver of the purchase.

To verify Cardholder activity, the Cardholder signature and date must be provided at the time of the transaction with the exception to Presidentially Declared Disasters. To validate the amount charged, Cardholder must include the actual amount paid. Note: This signature cannot be the Funding Official, Approval Official, or Receiver of the purchase.

This signature indicates the items purchased were received by the government. Normally the person that requested the items would sign indicating receipt of the requested items. If items were delivered to a remote location an email from the person receiving the items can be used. Packing lists from the shipments with “Received By:” and the persons printed name, date and signature is acceptable. The signature must be made by a government employee.

Note: This signature cannot be the Cardholder, Approving Official, or Funding Official.

Purchase Log ID Number or the Document ID number, if the bank system does not generate a Purchase Log ID Number.

Funding source for purchase. Attached a copy of the BPA if using as funding source for requested purchase.

Example: A BPA is used for shipping items via FedEx.

List the unit issue stated price listing (EA, BX, PG, RO, etc.).

Requestor needs to give enough information in the item description to make sure the correct items are purchased. You can insert more lines if necessary or you may indicate "See Attached Sheet" if items are listed on another document.

Unique number to identify the transaction. Determined by component.

Address supplies/services are to be delivered or consumed. Use the address where the goods are consumed for in-store purchases.

Information of the vendor that the requestor got the initial quote for supplies/services from. This may or may not be the actual vendor the items are purchased from based on the Required Sources of Supplies/Services. If the vendor changes at the time the order is placed based on mandatory sources or pricing the cardholder will annotate the vendor the items were actually purchased from in these blocks by lining through the information and writing in the actual.

Provide a 2-3 sentence narrative of why the supplies/services are needed. For training request, use the justification stated on the SF-182. Note: A copy of the SF-182 is required for all training classes.

1. Cardholder Name

2. Cardholder Telephone Number

3. Cardholder Email Address

4. Component

5. Program/Office

6. Requestor Name

7. Requestor Phone Number

8. Date of Request

9. Document ID Number

10. Ship to Address

11. City

12. State

13. Zip Code

14. Vendor Name

15. Vendor POC

16. Vendor Phone Number

17. Vendor Address

18. City

19. State

20. Zip Code

21. Detailed Justification for Purchase

22. Item #

23. Item Description

25. Quantity

26. Unit Issue

28. Subtotals Calculated field no input required. The subtotals should tie to the estimated order total.

29. Date Received

30. Accounting Data

31. Purchase Log ID Number

32. Estimated Total

33. Required Sources of Supplies

34. Funds Verification

35. Approving Official

36. Purchase Cardholder

37. Third Party Receipt

38. Property Accountability

39. Local Use Signature

PRIVACY ACT STATEMENT

AUTHORITY:

DHS is authorized to collect the information requested on this form pursuant to 40 U.S.C. § 501, Services for executive agencies; 40 U.S.C. § 502, Services for other entities; Executive Order 12931, Federal Procurement Reform; and DHS Management Directive 0760.1, Purchase Card Program.

PURPOSE:

DHS is requesting this information to establish and maintain a system for operating, controlling, and managing the purchase charge card program involving commercial purchases by authorized Federal government employees and contractors.

ROUTINE USES:

The information requested on this form may be shared externally as a "routine use" to assist DHS in conducting official duties associated with the management and operation of the purchase charge card program. A complete list of the routine uses can be found in the system of records notice associated with this form, "GSA/GOVT-6 GSA SmartPay Purchase Charge Card Program," available at http://www.dhs.gov/system-records-notices-sorns.

CONSEQUENCES OF FAILURE TO PROVIDE INFORMATION:

Providing this information to is voluntary. However, failure to provide this information may result in the loss or denial of the privileges of the Purchase Card Program.

NOTES:

* Invoice or confirmation of delivery must be attached.

* Special approval is required for all computer related purchases (Hardware, Software, Services).

* OMB A-123 requires that duties of approver, funding official, purchaser, and receiver be separate.

* Copy of SF-182 required for all training classes.

* Shipping charges of $100 or more requires a separate invoice or separate line item on invoice, quote, or receipt.

* If AO gives email approval for a purchase then the copy of the email approval must be attached.

8.2.1.3158.1.475346.466429

PURCHASE CARD TRANSACTION WORKSHEET

DHS

DHS

DHS

03/22/2022 03/22/2022