J-6_SF-1413.pdf

STATEMENT AND ACKNOWLEDGMENT

OMB No.: 9000-0014 Expires: 01/31/2008

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PART I - STATEMENT OF PRIME CONTRACTOR

1. PRIME CONTRACT NO. 2.DATE SUBCONTRACT

AWARDED

3. SUBCONTRACT NUMBER

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

8. PROJECT 9. LOCATION

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

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:

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

AUTHORIZED FOR LOCAL REPRODUCTION

PREVIOUS EDITION IS NOT USABLE

STANDARD FORM 1413 (REV. 7/2005)

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

4. PRIME CONTRACTOR

a. NAME

b. STREET ADDRESS

c. CITY d. STATE e. ZIP CODE

5. SUBCONTRACTOR

a. NAME

b. STREET ADDRESS

c. CITY d. STATE e. ZIP CODE

10b. TITLE OF PERSON SIGNING

15b. TITLE OF PERSON SIGNING

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

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

Overtime Compensation."

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 Davis-Bacon and Related Act Regulations

Davis-Bacon Act

Apprentices and Trainees

Compliance with Copeland Act Requirements

Subcontracts (Labor Standards)

Contract Termination - Debarment

Certification of Eligibility

A

B

C

D