Exhibit_III_-_CLOC_Reporting_Form.pdf

Exhibit 3: CLOC Reporting Form

CLOC REPORTING FORM

COMMODITY NAME: _____________________________ DISTRICT NAME: ____________________________________________

CLOC NO.: ____-_______-_______-________ CLOC PURCHASE PERIOD:___/___/___/ THROUGH___/___/___/

I CERTIFY THAT THE PRODUCTS CLAIMED BELOW ARE, TO THE BEST OF MY KNOWLEDGE, OF DOMESTIC ORIGIN AND WERE

ORDERED DURING THE PURCHASE PERIOD, SPECIFIED ABOVE.

DISTRICT REPRESENTATIVE:______________________________________ DATE:_________________________

1. PRODUCT DESCRIPTION

2. VENDOR

3. MONTH/YEAR OF ORDER

4. TOTAL COST

5. PERCENTAGE CREDIT

6. TOTAL CLAIMED (4X5)

APPROVAL YES NO YES NO YES NO YES NO

1. PRODUCT DESCRIPTION

2. VENDOR

3. MONTH/YEAR OF ORDER

4. TOTAL COST

5. PERCENTAGE CREDIT

6. TOTAL CLAIMED (4X5)

APPROVAL YES NO YES NO YES NO YES NO

Exhibit 3: CLOC Reporting Form

REVIEWED BY: _________________________________________________________ DATE REVIEWED:_________________________