Attach 03 - Work Sample Cover Sheet.docx

SOLICITATION ATTACHMENT 03

WORK SAMPLE COVER SHEET

This attachment is in support of solicitation H9240022R0008

PART I: WORK SAMPLE IDENTIFICATION

CONTRACTOR NAME:

CONTRACT NUMBER:

ORDER NUMBER (if applicable):

CUSTOMER (Agency/Organization):

TOTAL PERIOD OF PERFORMANCE, INCLUDING OPTIONS: (MM/YYYY –

MM/YYYY or MM/YYYY – Present)

WORK SAMPLE VALUE:

TASK ORDER AGAINST A MULTIPLE AWARD FEDERAL GOVERNMENT CONTRACT

FUNDING AGENCY ID

PART II: WORK SAMPLE INFORMATION/POINTS OF CONTACT

Contracting Officer

NAME:

TITLE:

AGENCY or CUSTOMER

PHONE

E-MAIL:

Contracting Officer’s Representative or Other Government Representative

NAME:

TITLE:

AGENCY or CUSTOMER

PHONE

E-MAIL:

Contracting Officer’s Representative or Other Government Representative

NAME:

TITLE:

AGENCY or CUSTOMER

PHONE

E-MAIL:

PART III: PROJECT DESCRIPTION (900 Character Limit)

PART IV: WORK SAMPLE VERIFICATION METHOD (OPTIONAL)

VERIFICATION METHOD: (Choose one) FPDS record (attached) ☐ Signature below by reference identified in Part II ☐

Signature below by a Contracting Officer, Contracting Officer’s Representative, Other Government Representative for the ordering activity constitutes acceptance of the above project information to be accurate as ordered and received by the listed entity

Instructions to Attachment 03 – Work Sample Cover Sheet

PART I: WORK SAMPLE IDENTIFICATION

Contractor Name: Enter the Contractor’s Name of this work sample.

Contract Number: Enter the Contract Number.

Order Number: Enter the Task Order Number if applicable.

Customer: Enter the Office Symbol and Program Name this work sample supports.

TOTAL PERIOD OF PERFORMANCE, INCLUDING OPTIONS: (MM/YYYY – MM/YYYY or MM/YYYY

– Present):

Work Sample Value: Enter the final or most recent total contract value of the work sample. Task Order Against A Multiple Award Federal Government Contract: Select Yes or No Funding Agency ID: Enter the Funding Agency ID utilized for the Work Sample.

Was this Work Sample Performed as the Prime Contractor? Select Yes if the Contractor listed under Contractor Name was the Prime under the Work Sample.

PART II: WORK SAMPLE INFORMATION/POINTS OF CONTACT

Contracting Officer: 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 or Other Government Representative: Provide the contact information for the Primary (or Alternate if Primary is not available) COR or if a COR is not available a Government Representative that would be able to assist in validation of the work sample.

Each Offeror shall provide at least two (2) Points of Contact (POCs) for each Work Sample.

PART III: WORK SAMPLE DESCRIPTION (900 Character Limit) This space is provided to allow the Offeror to present a brief synopsis of the work sample. The information provided will not be evaluated.

PART IV: WORK SAMPLE VERIFICATION METHOD (OPTIONAL)

After completing Parts I-III, provide this worksheet to the POCs listed under Part II. The POC should review the provided information from the Work Sample Cover Sheet, and only the Work Sample Cover Sheet, and their signature will verify that the information provided is accurate. If a POC is not available to sign the Cover Sheet the requested form of verification is to provide the most recent FPDS report for the contract. Part IV is optional but recommended to provide advance notice to the POCs that they may be contacted to support validation of the Work Sample.