Appendix_A_Work_Sample_Cover_Sheet.pdf

FA487724QA263 – Addendum to 52.212-1 Appendix

A WORK SAMPLE COVER SHEET

PART I: WORK SAMPLE IDENTIFICATION

WORK SAMPLE

IDENTIFIER:

CONTRACTOR NAME:

CONTRACT NUMBER:

TASK ORDER NUMBER:

CUSTOMER:

PERIOD OF

PERFORMANCE:

WORK SAMPLE VALUE

WORK SAMPLE

PERFORMED AS PRIME? Yes ☐ No ☐

SUBCONTRACT NUMBER

PART II: WORK SAMPLE POINTS OF CONTACT

1. Contracting Officer

NAME:

TITLE:

AGENCY or CUSTOMER

PHONE

E-MAIL:

2. Contracting Officer’s Representative or Relevant Customer Point of Contact

NAME:

TITLE:

AGENCY or CUSTOMER

PHONE

E-MAIL:

3. Prime Company Point of Contact

NAME:

TITLE:

COMPANY

PHONE

E-MAIL:

PART III: PROJECT DESCRIPTION (500 Character Limit)

Instructions to Addendum to 52.212-1, Appendix A – Work Sample Cover Sheet

DELETE THIS PAGE UPON COMPLETION OF THE WORK SAMPLE COVER SHEET

Offerors shall follow the instructions below when filling out Addendum to 52.212-1 Appendix A - Work Sample Cover Sheet.

PART I: WORK SAMPLE IDENTIFICATION

Work Sample Identifier: Works samples shall be numbered WS1-WS15. Insert the applicable work sample number.

Contractor Name: Offerors shall enter the Contractor’s Name of this work sample.

Contract Number: Offerors shall enter the Contract Number.

Task Order Number: Offerors shall enter the Task Order Number (if applicable).

Customer: Offerors shall enter the agency, organization, or client name. If the customer was a Government agency, or organization, Offerors shall include the office symbol and program name this work sample supports.

Period of Performance: Offerors shall include the period of performance if the contract/order including all options. Offerors shall list the period of performance in the following format (MM/YYYY – MM/ YYYY or MM/YYYY – Present):

Work Sample Value: Offerors shall enter the final or most recent total contract/order value of the work sample. The total value shall include the value of all options.

Was this Work Sample Performed as the Prime Contractor? The Offeror shall select ‘Yes’ if the Contractor listed under Contractor Name was the Prime under the work sample.

Subcontract Number: If Contractor listed under Contractor Name was not the Prime under the work sample, Offeror shall enter the Subcontract Number.

PART II: WORK SAMPLE POINTS OF CONTACT

Contracting Officer: Offerors shall provide the contact information for either the current Contracting Officer working the contract or the most recent Contracting Officer if the contract has ended. If there is no available Contracting Officer then leave this section blank.

Contracting Officer’s Representative (COR) or Relevant Customer Point of Contact: Offerors shall provide the contact information for the Primary (or Alternate if Primary is not available) COR. If a COR is not available, or if the work sample is not for a Government contract, Offerors shall provide a relevant customer point of contact that would be able to assist in validation of the work sample.

Prime Company Point of Contact. If the offeror was a sub-contractor they shall provide the contract information for the Prime Contractor. If the offeror was the Prime, then leave this section blank.

PART III: WORK SAMPLE DESCRIPTION (500 Character Limit) Offerors shall provide a brief description of the work sample. If the Offeror uses a subsidiary or legal entity work sample as a prime work sample, the Offeror may use this section to describe the relationship.