Attachment 3 - DHS_Form_700-21.pdf
DHS Form PDF 587 KB Posted
- Solicitation number
- 70Z08426QWOPL0007
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DHS Form 700-21: Material Inspection Acceptance and Receiving Report
This is a Department of Homeland Security standard form used to document the inspection, acceptance, and receipt of materials and services under federal contracts. The form serves as an official receiving and quality control document that records whether delivered items or performed services conform to contract requirements.
The form captures essential contract and delivery information including contract number, modification number, order number, report number, contractor name, manufacturer, and delivery location. It documents inspection activity through specific date fields (received, ready, started, and completed) and tracks quantities across multiple categories: rejected, accepted in the current report, and cumulative totals to date. The form requires identification of the contract line item number(s) applicable to the inspection. A remarks section allows for detailed notes regarding any deviations or special authorizations. The inspecting official must certify that materials and services listed as accepted conform to contract requirements, while those rejected do not conform and may not be delivered except as authorized under remarks. The form requires signature, printed name, title, telephone number, and date from the inspecting official, along with the same information from the supervising authority if applicable. This two-page form includes a continuation sheet for reporting on multiple line items or providing additional documentation.
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Text version
DATE
1. CONTRACT NO. AND LATEST
MODIFICATION NO.
2. ORDER NO. 3. REPORT NO.
4. MATERIAL AND/OR SERVICES INSPECTED
5. CONTRACTOR
7. MANUFACTURER
8. PLACE OF INSPECTION
DHS Form 700-21 (10/14) Page 1 of 2
PREVIOUS
REPORTS
16. SUBMITTED
17. REJECTED
18. ACCEPTED
19. QUANTITY ON
ORDER
22. REMARKS (Use Continuation Sheet for Additional Entries)
23. INSPECTED BY 24. TITLE AND TELEPHONE NUMBER
The materials and/or services listed herein have been inspected or certified test data has been examined, by me or under my supervision.
The materials and/or services listed above as accepted conform to contract requirements. Those listed as rejected do not conform and may not be delivered, except as authorized under "Remarks."
25. SIGNATURE AND PRINTED NAME 26. TITLE AND TELEPHONE NUMBER 27. DATE
DEPARTMENT OF HOMELAND SECURITY
MATERIAL INSPECTION ACCEPTANCE AND RECEIVING REPORT
CONTRACT LINE
ITEM NO(S)
(If applicable)
9.
15. ACCEPTED14. REJECTED
QUANTITY
13. COMPLETED12. STARTED11. READY10. RECEIVED
INSPECTION DATES
20. ACCEPTED TO
DATE
21. BALANCE
REMAINING
THIS
REPORT
TOTAL
TO DATE
6. LOCATION WHERE ITEMS WERE DELIVERED OR
CONTRACTOR PERFORMED
3. REPORT NO.
DEPARTMENT OF HOMELAND SECURITY
MATERIAL INSPECTION ACCEPTANCE AND RECEIVING REPORT (Continued)
CONTRACT LINE
ITEM NO(S)
(If applicable)
9.
15. ACCEPTED14. REJECTED
QUANTITY
13. COMPLETED12. STARTED11. READY10. RECEIVED
INSPECTION DATES
Page 2 of 2DHS Form 700-21 (10/14)
Material Inspection Acceptance and Receiving Report, December 2003 U.S. Department of Homeland Security, Acquisition Policy and Legislation D:20040317145138- 05'00' D:20051012110539- 04'00'
DATE
1. CONTRACT NO. AND LATEST
MODIFICATION NO.
2. ORDER NO.
3. REPORT NO.
4. MATERIAL AND/OR SERVICES INSPECTED
5. CONTRACTOR
7. MANUFACTURER
8. PLACE OF INSPECTION
DHS Form 700-21 (10/14)
PREVIOUS REPORTS
16. SUBMITTED
17. REJECTED
18. ACCEPTED
19. QUANTITY ON ORDER
22. REMARKS (Use Continuation Sheet for Additional Entries)
23. INSPECTED BY
24. TITLE AND TELEPHONE NUMBER
The materials and/or services listed herein have been inspected or certified test data has been examined, by me or under my supervision. The materials and/or services listed above as accepted conform to contract requirements. Those listed as rejected do not conform and may not be delivered, except as authorized under "Remarks."
The materials and/or services listed herein have been inspected or certified test data has been examined, by me or under my supervision. The materials and/or services listed above as accepted conform to contract requirements. Those listed as rejected do not conform and may not be delivered, except as authorized under Remarks.
25. SIGNATURE AND PRINTED NAME
26. TITLE AND TELEPHONE NUMBER
27. DATE
DEPARTMENT OF HOMELAND SECURITY
MATERIAL INSPECTION ACCEPTANCE AND RECEIVING REPORT
CONTRACT LINE
ITEM NO(S)
(If applicable) 9.
15. ACCEPTED
14. REJECTED
QUANTITY
13. COMPLETED
12. STARTED
11. READY
10. RECEIVED
INSPECTION DATES
20. ACCEPTED TO DATE
21. BALANCE REMAINING
THIS
REPORT
TOTAL
TO DATE
6. LOCATION WHERE ITEMS WERE DELIVERED OR
CONTRACTOR PERFORMED
3. REPORT NO.
DEPARTMENT OF HOMELAND SECURITY
MATERIAL INSPECTION ACCEPTANCE AND RECEIVING REPORT (Continued)
CONTRACT LINE
ITEM NO(S)
(If applicable) 9.
15. ACCEPTED
14. REJECTED
QUANTITY
13. COMPLETED
12. STARTED
11. READY
10. RECEIVED
INSPECTION DATES
DHS Form 700-21 (10/14)
| 9. CONTRACT LINE ITEM NUMBER(S) (If applicable) Line 38 of 38.: |
| 15. Quantity Accepted: |
| 14. Quantity REJECTED: |
| Inspection Dates. 13. Completed Date. Enter 2-digit month, 2-digit day and 4-digit year.: |
| Inspection Dates. 12. Started Date. Enter 2-digit month, 2-digit day and 4-digit year.: |
| Inspection Dates. 11. Ready Date. Enter 2-digit month, 2-digit day and 4-digit year.: |
| Inspection Dates. 10. Received Date. Enter 2-digit month, 2-digit day and 4-digit year.: |
| Date. Enter 2-digit month, 2-digit day and 4-digit year.: |
| 1. Contract Number and Latest Modification Number.: |
| 2. ORDER NUMBER.: |
| 4. MATERIAL AND/OR SERVICES INSPECTED.: |
| 5. CONTRACTOR.: |
| 7. MANUFACTURER: |
| 8. PLACE OF INSPECTION: |
| 16. SUBMITTED. PREVIOUS REPORTS: |
| 16. SUBMITTED. THIS REPORT: |
| 16. SUBMITTED. TOTAL TO DATE: |
| 17. REJECTED. TOTAL TO DATE: |
| 17. REJECTED. THIS REPORT: |
| 17. REJECTED. PREVIOUS REPORTS: |
| 18. ACCEPTED. TOTAL TO DATE: |
| 18. ACCEPTED. THIS REPORT: |
| 18. ACCEPTED. PREVIOUS REPORTS: |
| 22. REMARKS (Use Continuation Sheet for Additional Entries). : |
| 23. INSPECTED BY.: |
| 24. TITLE.: |
| 26. TITLE. : |
| 27. DATE. Enter 2-digit month, 2-digit day and 4-digit year.: |
| 19. QUANTITY ON ORDER: |
| 20. ACCEPTED TO DATE: |
| 21. BALANCE REMAINING: |
| 25. PRINTED NAME.: |
| 3. REPORT NUMBER. : |
| 6. LOCATION WHERE ITEMS WERE DELIVERED OR CONTRACTOR PERFORMED.: |
| 26. Telephone Number. Enter 10 digit telephone number including area code.: |
| 25. SIGNATURE. Digital Signature.: |
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