Attachment_5_SF-1413_Statement_and_Acknowledgement_Form_(Subcontracting).pdf
PDF 70 KB Posted
- Attached to
- OUTDOOR RECREATION SPORT COURT
- Solicitation number
- 140A2324R0017
About this file
This document contains a Statement and Acknowledgment form to be completed by prime and subcontractors for a federal contract opportunity issued by the Department of the Interior Bureau of Indian Affairs Bureau of Indian Education. The form requires the prime contractor to provide the prime contract number, date of subcontract award, subcontract number and identifying information for both the prime contractor and subcontractor. The prime contractor must also indicate whether the prime contract contains a clause for Contract Work Hours and Safety Standards Act overtime compensation. Additionally, the form requires the subcontractor to acknowledge inclusion of standard labor law clauses in the subcontract and provide the name of any intermediate subcontractors. Both the prime contractor and subcontractor representatives must sign and date the completed form.
The related federal contract opportunity is for outdoor recreation sport courts with a solicitation number of 140A2324R0017. The opportunity was issued by the Department of the Interior Bureau of Indian Affairs Bureau of Indian Education. No further details are provided on requirements, response dates, pricing or other salient terms.
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Text version
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.
File details come from the government source that posted it. Updated .