AMS-Form-022.docx

PROCUREMENT AND PROPERTY MANAGEMENT DIVISION

BROOKHAVEN NATIONAL LABORATORY

Managed by Brookhaven Science Associates, LLC under contract to the U.S. Department of Energy

ACQUISITION MANAGEMENT SYSTEM FORM

Form No. AMS-Form-022

Revision No. 1.0

APPROVED BY:

A. Guadagni 11/3/16

PPM Manager/Date

FINAL RELEASE OF CLAIM

Contractor:

Address:

The work under Contract No. between the above-named Contractor and Brookhaven Science Associates, LLC (BSA), has been completed. In consideration of the total payment on account of the Contract in the sum of $ made by BSA, the undersigned Contractor hereby releases Brookhaven Science Associates, LLC, its officers, agents and employees and the Government of the United States, its agents and employees, from any and all claims arising under the Contract or in connection with the work required to be performed thereunder, and hereby agrees to indemnify Brookhaven Science Associates, LLC and the Government of the United States against, and to hold each of them harmless from, any claims by any person arising out of or in any way connected with the Contract or the work hereunder. The following are excepted from the foregoing release and agreement:

Executed:

Witness:

Signature:

Signature:

Typed Name:

Typed Name:

Title:

Title:

Date:

Date:

I, ____________________________, certify that I am the President/Secretary of the corporation named as Contractor herein, that ___________________________, who signed this Release on behalf of the Contractor, was then ____________________________, of said corporation, that said Release was duly signed for and in behalf of said corporation by authority of its governing body, and is within the scope of its corporate powers.

Signature:

Place:

Date:

Date Printed 11/3/2016 1 of 1