Attachment 7-DHS Form 1501 April 2017.pdf

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Page of DHS Form 1501 (4/17) 22.

Item #

2. Cardholder Telephone Number:

1. Name of Cardholder:

10. Ship To Address:

14. Vendor Name:

17. Vendor Address:

21. Detailed Justification for Purchase:

23.

Item Description

15. Vendor POC:

12. State:

16. Vendor Phone Number:

19. State:

24.

Stock Number

18. City:

DEPARTMENT OF HOMELAND SECURITY

PURCHASE CARD TRANSACTION WORKSHEET

7. Requestor Phone Number:

3. Cardholder Email Address:

8. Date of Request:

11. City:

4. Component:

9. Document ID Number:

5. Program/Office:

6. Requestor Name:

13. Zip Code:

20. Zip Code:

25.

Quantity 26.

Unit of Issue 27.

Unit Price 28.

Subtotals 29.

Date Received

38. PROPERTY CUSTODIAN INFORMATION (Property Accountability)

37. ALL THE ABOVE ITEMS HAVE BEEN RECEIVED AND ACCEPTED (Third Party- Cannot be the cardholder or the approving official)

36. PURCHASE CARD HOLDER INFORMATION

35. APPROVING OFFICIAL/ALTERNATE APPROVING OFFICIAL INFORMATION

34. FUNDS VERIFICATION OFFICIAL INFORMATION Note: Attach all documents BEFORE signing

39. LOCAL USE SIGNATURES (If needed)

ACCS

30. Accounting Data:

32. ESTIMATED ORDER TOTAL:

31. Purchase Log ID:

33. TO REQUIRED SOURCES for SUPPLIES TO REQUIRED SOURCES for SERVICES

TO SPECIAL APPROVALS NEEDED

1. Agency Inventories

2. Excess from other Agencies

3. UNICOR

6. Optional Use GSA/FSS or DHS BPAs

5. Wholesale Supply Sources

4. Ability One

1. ABILITY ONE

2. Optional Use Unicor

4. Optional Use of Federal Supply Schedules

5. Commercial

1. IT Request

3. Branding

5. OGC-Awards

4. Legal

2. Printing

7. Optional Use Federal Supply Schedules

8. Commercial

3. Optional Use GSA/FSS or DHS BPAs

6. Accountable Property

7. Other

NOTES:

* Invoice or confirmation of delivery must be attached.

* Special approval is required for all computer related purchases (Hardware, Software, Services). Attach Approved ITS.

* OMB A-123 requires that duties of approver, purchaser, and receiver be separate.

* Copy of SF-182 required for all training classes.

* Shipping charges $100 or more requires a separate invoice.

* If AO gives email approval for purchase a copy of an email indicating this must be attached.

The following guidance should be used to complete the Purchase Card Worksheet. This worksheet provides a consolidated source for documenting and tracking purchase card requirements as established by applicable laws, regulations, and guidance. You must retain this form and all supporting documents in a central location for auditing purposes. This worksheet, along with the applicable documentation, should be submitted to the Component's Organization Program Coordinator for review during the Post Payment Audit process. Please contact the Component's primary organization program coordinator for any questions.

Purchase Card Worksheet Guidance Field Guidance Name of the actual cardholder making the purchase.

Phone number of the cardholder.

Email address of the cardholder.

Component where the cardholder works.

Physical location where the cardholder works.

Name of person requesting the supplies/services. Requestor cannot be the cardholder.

Phone number of person requesting the supplies/services.

Date the requestor submits the request.

N/A - Count function only.

Number of items requested.

The date the item was actually received.

Calculated field no input required if filling out in excel. If written then the unit price times the quantity.

Use as a check list to make sure you are looking at required sources in the proper sequence. If you are unable to satisfy requirements for supplies and services from the required sources listing then you are encouraged to consider satisfying requirements through other sources which have been identified as Optional Use. Please note: Optional use sources of supplies and services are not listed in any order of priority.

Required for all items that require accountability.

These blocks can be used to put in any locally required approvals if needed. Some offices require some internal approvals based on total cost, prior to the purchase being made. If none are required for your office, you can remove them from the PCTW.

Signature and date of person authorized to validate funds availability. Date must be PRIOR to the purchase being made. Can be an email if official is not physically available to sign prior to the purchase.

The card holders approving official (that is set up in the bank system) signs and dates PRIOR to the purchase being made. Typed name may be prepopulated by the card holder. It can be an email from the approving official if they are not physically available to sign prior to the purchase.

Card holder signs, puts date purchase was actually made and the actual amount paid.

This signature indicates the items purchased were received by the government. Normally the person that requested the items would sign indicating receipt of the requested items. If items were delivered to a remote location an email from the person receiving the items can be used. Packing lists from the shipments with “Received By:” and the persons printed name, date and signature is acceptable. This signature can not be the card holder, approving official, or alternate approving official of the card holder making the purchase. The signature must be made by a government employee.

Purchase Log ID Number or the Document ID number, if the bank system does not generate a Purchase Log ID Number.

Funding source for purchase. Attached a copy of the BPA if using as funding source for requested purchase.

Example: A BPA is used for shipping items via FedEx.

List the unit issue stated price listing (EA, BX, PG, RO, etc.).30Unit Price List the price of the requested item. The sum of unit pricing should tie to the estimated total.

Requestor needs to give enough information in the item description to make sure the correct items are purchased. You can insert more lines if necessary or you may indicate "See Attached Sheet" if items are listed on another document.

Unique number to identify the transaction. Determined by component.

Address supplies/services are to be delivered or consumed. Use the address where the goods are consumed for in-store purchases.

Information of the vendor that the requestor got the initial quote for supplies/services from. This may or may not be the actual vendor the items are purchased from based on the Required Sources of Supplies/Services. If the vendor changes at the time the order is placed based on mandatory sources or pricing the cardholder will annotate the vendor the items were actually purchased from in these blocks by lining through the information and writing in the actual.

Provide a 2-3 sentence narrative of why the supplies/services are needed for. Use the justification stated on the SF-182 for training request use the information.

1. Cardholder Name

2. Cardholder Telephone Number

3. Cardholder Email Address

4. Component

5. Program/Office

6. Requestor Name

7. Requestor Phone Number

8. Date of Request

9. Document ID Number

10. Ship to Address

11. City

12. State

13. Zip Code

14. Vendor Name

15. Vendor POC

16. Vendor Phone Number

17. Vendor Address

18. City

19. State

20. Zip Code

21. Detailed Justification for Purchase

22. Item #

23. Item Description

25. Quantity

26. Unit Issue

28. Subtotals

29. Date Received

30. Accounting Data

31. Purchase Log ID Number

32. Estimated Total

33. Required Sources of Supplies

34. Funds Verification

35. Approving Official

36. Purchase Card Holder

37. Third Party Receipt

38. Property Accountability

39. Local Use Signature

PRIVACY ACT STATEMENT

AUTHORITY:

DHS is authorized to collect the information requested on this form pursuant to 40 U.S.C. § 501, Services for executive agencies; 40 U.S.C. § 502, Services for other entities; Executive Order 12931, Federal Procurement Reform; and DHS Management Directive 0760.1, Purchase Card Program.

PURPOSE:

DHS is requesting this information to establish and maintain a system for operating, controlling, and managing the purchase charge card program involving commercial purchases by authorized Federal government employees and contractors.

ROUTINE USES:

The information requested on this form may be shared externally as a "routine use" to assist DHS in conducting official duties associated with the management and operation of the purchase charge card program. A complete list of the routine uses can be found in the system of records notice associated with this form, "GSA/GOVT-6 GSA SmartPay Purchase Charge Card Program," available at http://www.dhs.gov/system-records-notices-sorns.

CONSEQUENCES OF FAILURE TO PROVIDE INFORMATION:

Providing this information to is voluntary. However, failure to provide this information may result in the loss or denial of the privileges of the Purchase Card Program.

8.2.1.3158.1.475346.466429

PURCHASE CARD TRANSACTION WORKSHEET

DHS Form 1501