Attachment_2_SF1413_Statement_and_Acknowledgement.pdf

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HVAC Hot Water Supply Line Repair
Solicitation number
140A2326Q0288
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This is Standard Form 1413 (Rev. 4/2013), a federal contracting form prescribed by GSA/FAR (48 CFR 53.222(e)) for documenting subcontract awards under prime federal contracts. The form serves as a statement and acknowledgment mechanism between prime contractors and their subcontractors.

Part I requires the prime contractor to document subcontract award information, including the prime contract number, subcontract number, award date, and identification of both the prime contractor and subcontractor with their complete addresses. The prime contractor must indicate whether the prime contract contains the "Contract Work Hours and Safety Standards Act -- Overtime Compensation" clause and identify the awarding firm, description of subcontracted work, project name, and work location. Part II requires the subcontractor to acknowledge receipt of specific labor standards clauses incorporated from the prime contract, including provisions related to contract work hours, payrolls, withholding of funds, disputes concerning labor standards, construction wage rate requirements, apprentices and trainees, Copeland Act compliance, subcontracts, contract termination/debarment, and certification of eligibility. The form also provides space to identify any intermediate subcontractors. Both the prime contractor representative and subcontractor representative must sign and date their respective sections. The form includes paperwork reduction act compliance information indicating an estimated completion time of 0.05 hours and OMB Control Number 9000-0066 with an expiration date of 5/31/2025.

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STATEMENT AND ACKNOWLEDGMENT OMB Control Number: 9000-0066 Expiration Date: 5/31/2025

PART I - STATEMENT OF PRIME CONTRACTOR

1. PRIME CONTRACT NUMBER 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 - This information collection meets the requirements of 44 U.S.C. § 3507, as amended by section 2 of the Paperwork Reduction Act of 1995. You do not need to answer these questions unless we display a valid Office of Management and Budget (OMB) control number.

The OMB control number for this collection is 9000-0066. We estimate that it will take .05 hours to read the instructions, gather the facts, and answer the questions. Send only comments relating to our time estimate, including suggestions for reducing this burden, or any other aspects of this collection of information to: U.S. General Services Administration, Regulatory Secretariat Division (M1V1CB), 1800 F Street, NW, Washington, DC 20405.

1.6 Presentation Agent PDFlib 3.02 (C++/Win32) D:20050617125503-04'00' D:20080212101247-05'00' Presentation Agent Standard Form 1413 - Statement and Acknowledgment

STATEMENT AND ACKNOWLEDGMENT

OMB Control Number: 9000-0066 Expiration Date: 5/31/2025

PART I - STATEMENT OF PRIME CONTRACTOR

1. PRIME CONTRACT NUMBER

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 - This information collection meets the requirements of 44 U.S.C. § 3507, as amended by section 2 of the Paperwork Reduction Act of 1995. You do not need to answer these questions unless we display a valid Office of Management and Budget (OMB) control number. The OMB control number for this collection is 9000-0066. We estimate that it will take .05 hours to read the instructions, gather the facts, and answer the questions. Send only comments relating to our time estimate, including suggestions for reducing this burden, or any other aspects of this collection of information to: U.S. General Services Administration, Regulatory Secretariat Division (M1V1CB), 1800 F Street, NW, Washington, DC 20405.

1. PRIME CONTRACT NUMBER:
4A. NAME:
4B. STREET ADDRESS:
4C. CITY:
7A. NAME OF AWARDING FIRM:
10A. NAME OF PERSON SIGNING:
15A. NAME OF PERSON SIGNING:
15B. TITLE OF PERSON SIGNING:
10B. TITLE OF PERSON SIGNING:
14. NAME(S) OF ANY INTERMEDIATE SUBCONTRACTORS, IF ANY. Line A.:
14. NAME(S) OF ANY INTERMEDIATE SUBCONTRACTORS, IF ANY. Line D.:
14. NAME(S) OF ANY INTERMEDIATE SUBCONTRACTORS, IF ANY. Line C.:
14. NAME(S) OF ANY INTERMEDIATE SUBCONTRACTORS, IF ANY. Line B.:
8. PROJECT:
9. LOCATION:
7B. DESCRIPTION OF WORK BY SUBCONTRACTOR:
5C. CITY:
4E. ZIP CODE:
5E. ZIP CODE:
4D. STATE:
5D. STATE:
3. SUBCONTRACT NUMBER:
5A. NAME:
5B. STREET ADDRESS:
2. DATE SUBCONTRACT AWARDED. Enter 2 digit month, 2 digit day and 4 digit year.:
12. DATE SIGNED. Enter 2 digit month, 2 digit day and 4 digit year.:
17. DATE SIGNED. Enter 2 digit month, 2 digit day and 4 digit year.:
6. The prime contract does contain the clause entitled "Contract Work Hours and Safety Standards Act -- Overtime Compensation.": 0
6. The prime contract does not contain the clause entitled "Contract Work Hours and Safety Standards Act -- Overtime Compensation.": 0
Sign here if you are the Subcontractor.:

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