Attachment_8_SF1413_Statement_and_Acknowledgement.pdf
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- Attached to
- Havasupai Elementary School - Fire Pull Station
- Solicitation number
- 140A2326Q0145
About this file
This document is Standard Form 1413 (Rev. 4/2013), a federal Statement and Acknowledgment form prescribed by the General Services Administration under the Federal Acquisition Regulation (48 CFR 53.222(e)). The form serves as a template for documenting subcontract awards under prime federal contracts and ensuring compliance with labor standards requirements.
Part I of the form requires the prime contractor to provide essential subcontract information, including the prime contract number, subcontract number, award date, and identification of both the prime contractor and subcontractor with their respective addresses. The prime contractor must indicate whether the prime contract contains the "Contract Work Hours and Safety Standards Act – Overtime Compensation" clause and must identify the awarding firm, describe the work to be performed by the subcontractor, specify the project and location, and include the name, title, and signature of an authorized representative. Part II requires the subcontractor to acknowledge that specific labor standards clauses are incorporated into the subcontract, including provisions related to contract work hours and safety standards, payrolls and basic records, withholding of funds, disputes concerning labor standards, construction wage rate requirements, apprentices and trainees, Copeland Act compliance, subcontracts (labor standards), contract termination and debarment, and certification of eligibility. The form also provides space for listing any intermediate subcontractors and requires signatures and dates from authorized subcontractor personnel. The OMB Control Number is 9000-0066 with an expiration date of 5/31/2025, and the estimated burden is 0.05 hours to complete.
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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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