B01 Exhibit 1-DD Form 1844.pdf

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Attached to
Direct Procurement Method (DPM)
Solicitation number
W9124A-20-R-0023
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AMOUNT

ALLOWED

1. NAME OF CLAIMANT (Last, First, Middle Initial) 3. PICK-UP DATE

(YYYYMMDD) LIST OF PROPERTY AND CLAIMS ANALYSIS CHART

(Items 14 through 31 to be filled out by Claims Office)

2. CLAIMANT'S INSURANCE COMPANY (If applicable)

a. NAME b. POLICY NO.

4. DELIVERY DATE

(YYYYMMDD)

14. ORIGIN CONTRACTOR 17. 2ND CONTRACTOR 21. CLAIM NUMBER 22. NET WT/MAX CAR

15. INVENTORY DATE

(YYYYMMDD)

18. EXCEPTION SHEET

DATE (YYYYMMDD)

23. GBL NUMBER 24. LOT NUMBER5.

LINE

NO.

6.

QTY

7. LOST OR DAMAGED ITEMS

(Describe the item fully, including brand name, model and size. List the nature and extent of damage. If missing, state "MISSING.")

8.

INV

NO.

9. ORIGINAL

COST

11. AMOUNT

CLAIMED

a. Repair Cost

10.

MM/YYYY

PURCHASED

(or) b.

Replace-ment Cost

16.

EXCEPTIONS

19.

INV

NO.

20.

EXCEPTIONS

25.

ADJUDICATOR'S

REMARKS

26.

ITEM

WT

27.

HOUSE

LIABILITY

28.

CARRIER

LIABILITY

29.

12. REMARKS 13. TOTAL

$ 30. TOTAL

AMOUNT

ALLOWED

$ 31. THIRD

PARTY

LIABILITY

DD FORM 1844, MAY 2000 PREVIOUS EDITION IS OBSOLETE. Page of Pages

claim_name:
pickup:
ins_name:
pol_no:
deliv:
line_1:
qty1:
lost1:
inv_1:
orig_cost1:
purch1:
rep_cost1:
repl_cost1:
line_2:
qty2:
lost2:
inv_2:
orig_cost2:
purch2:
rep_cost2:
repl_cost2:
line_3:
qty3:
lost3:
inv_3:
orig_cost3:
purch3:
rep_cost3:
repl_cost3:
line_4:
qty4:
lost4:
inv_4:
orig_cost4:
purch4:
rep_cost4:
repl_cost4:
line_5:
qty5:
lost5:
inv_5:
orig_cost5:
purch5:
rep_cost5:
repl_cost5:
line_6:
qty6:
lost6:
inv_6:
orig_cost6:
purch6:
rep_cost6:
repl_cost6:
line_7:
qty7:
lost7:
inv_7:
orig_cost7:
purch7:
rep_cost7:
repl_cost7:
line_8:
qty8:
lost8:
inv_8:
orig_cost8:
purch8:
rep_cost8:
remarks:
repl_cost8:
total_cost: 0
orig_ctr:
inv_date:
ctr2:
exc_sheet:
claim_no:
netwt:
gbl_no:
lot_no:
exc1_1:
invno_1:
exc2_1:
amt_all1:
adj_rmks1:
item_wt1:
house1:
carr1:
exc1_2:
invno_2:
exc2_2:
amt_all2:
adj_rmks2:
item_wt2:
house2:
carr2:
exc1_3:
invno_3:
exc2_3:
amt_all3:
adj_rmks3:
item_wt3:
house3:
carr3:
exc1_4:
invno_4:
exc2_4:
amt_all4:
adj_rmks4:
item_wt4:
house4:
carr4:
exc1_5:
invno_5:
exc2_5:
amt_all5:
adj_rmks5:
item_wt5:
house5:
carr5:
exc1_6:
invno_6:
exc2_6:
amt_all6:
adj_rmks6:
item_wt6:
house6:
carr6:
exc1_7:
invno_7:
exc2_7:
amt_all7:
adj_rmks7:
item_wt7:
house7:
carr7:
exc1_8:
invno_8:
exc2_8:
amt_all8:
adj_rmks8:
item_wt8:
house8:
carr8:
total_all: 0
total_house: 0
total_carr: 0
page:
pages:
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