Attachment 12 DOT Contractor Release.pdf

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Microsoft Word - frm4220_4.doc laverne.taylor 11.0.0.20130303.1.892433 Form DOT F 4220.4 (Rev. 5/05)

PREVIOUS EDITION OBSOLETE

AUTHORIZED FOR LOCAL REPRODUCTION

DEPARTMENT OF TRANSPORTATION

CONTRACTOR'S RELEASE

CONTRACTOR (Name and Address)

CONTRACT NO.

ENTER SUM OF TOTAL OF AMOUNTS PAID AND PAYABLE

Pursuant to the terms of the above numbered contract and in consideration of the sum stated above, which has been paid or is to be paid to the Contractor, or its assignees, the Contractor, upon payment of the said sum by the UNITED STATES OF AMERICA (hereinafter called the Government), does remise, release, and discharge the Government, its officers, agents, and employees, of and from all liabilities, obligations, claims, and demands whatsoever under or arising from the said contract, except:

1. Specified claims in stated amounts or in estimated amounts where the amounts are not susceptible of exact statement by the Contractor, as follows: (or state "None")

2. Claims, together with reasonable expenses incidental thereto, based upon the liabilities of the Contractor to third parties arising out of the performance of this contract, which are not known to the Contractor on the date of the execution of this release and of which the Contractor gives notice in writing to the Contracting Officer within the period specified in the said contract; and

3. Claims for reimbursement of costs (other than expenses of the Contractor by reason of his indemnification of the Government against patent liability) including reasonable expenses incidental thereto, incurred by the Contractor under any provisions of the said contract relating to patents.

The Contractor agrees, in connection with patent matters and with claims which are not released as set forth above, that it will comply with all provisions of the said contract, provisions of the said contract, including without limitation those provisions relating to notification to the Contracting Officer and relating to the defense or prosecution of litigation.

IN WITNESSES WHEREOF, this release has been executed this

WITNESSES

(Contractor)

BY

TITLE

NOTE: In the case of a corporation, witnesses are not required but the below statement must be completed.

secretary of the corporation who signed said release on behalf of said corporation; 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 day of , 20 I, , am the named as Contractor in the foregoing release; that of the Contractor was then