Attachment 11 - SF1413 - DRAFT.pdf

STATEMENT AND ACKNOWLEDGMENT OMB Control Number: 9000-0014 Expiration Date: 12/31/2017

PART I - STATEMENT OF PRIME CONTRACTOR

1. PRIME CONTRACT NO. 2. DATE SUBCONTRACT

AWARDED

3. SUBCONTRACT NUMBER

15b. TITLE OF PERSON SIGNING

AUTHORIZED FOR LOCAL REPRODUCTION

PREVIOUS EDITION IS NOT USABLE

STANDARD FORM 1413 (REV. 4/2013)

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

4. PRIME CONTRACTOR 5. SUBCONTRACTOR

a. NAME a. NAME

b. STREET ADDRESS b. STREET ADDRESS

c. CITY d. STATE e. ZIP CODE c. CITY d. STATE e. ZIP CODE

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

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

8. PROJECT 9. LOCATION

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

10b. TITLE OF PERSON SIGNING

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:

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 Construction Wage Rate Requirements and Related Regulations

Construction Wage Rate Requirements Apprentices and Trainees Compliance with Copeland Act Requirements Subcontracts (Labor Standards) Contract Termination - Debarment Certification of Eligibility

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

A C

B D

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

PAPERWORK REDUCTION ACT STATEMENT: Public reporting burden for this collection of information is estimated to average .05 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspects of this collection of information, including suggestions for reducing this burden, to U.S. General Services Administration, Regulatory Secretariat (MVCB)/IC 9000-0014, Office of Governmentwide Acquisition Policy,1800 F Street, NW, Washington, DC 20405.

1.6 Presentation Agent PDFlib 3.02 (C++/Win32) D:20050617125503-04'00' D:20080212101247-05'00'

STATEMENT AND ACKNOWLEDGMENT

OMB Control Number: 9000-0014 Expiration Date: 12/31/2017

PART I - STATEMENT OF PRIME CONTRACTOR

1. PRIME CONTRACT NO.

2. DATE SUBCONTRACT AWARDED

3. SUBCONTRACT NUMBER

15b. TITLE OF PERSON SIGNING

AUTHORIZED FOR LOCAL REPRODUCTION PREVIOUS EDITION IS NOT USABLE

STANDARD FORM 1413 (REV. 4/2013)

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

4. PRIME CONTRACTOR

5. SUBCONTRACTOR

a. NAME

a. NAME

b. STREET ADDRESS

b. STREET ADDRESS

c. CITY

d. STATE

e. ZIP CODE

c. CITY

d. STATE

e. ZIP CODE

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

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

8. PROJECT

9. LOCATION

10a. NAME OF PERSON SIGNING

11. BY (Signature)

12. DATE SIGNED

10b. TITLE OF PERSON SIGNING

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:

Contract Work Hours and Safety Standards Act - Overtime Compensation (If included in prime contract see Block 6) Payrolls and Basic RecordsWithholding of FundsDisputes Concerning Labor StandardsCompliance with Construction Wage Rate Requirements and Related Regulations Construction Wage Rate Requirements Apprentices and Trainees Compliance with Copeland Act Requirements Subcontracts (Labor Standards) Contract Termination - Debarment Certification of Eligibility

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

A C B D 15a. NAME OF PERSON SIGNING

16. BY (Signature)

17. DATE SIGNED

PAPERWORK REDUCTION ACT STATEMENT: Public reporting burden for this collection of information is estimated to average .05 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspects of this collection of information, including suggestions for reducing this burden, to U.S. General Services Administration, Regulatory Secretariat (MVCB)/IC 9000-0014, Office of Governmentwide Acquisition Policy,1800 F Street, NW, Washington, DC 20405.