B08 - Attachment 0014 - Item Information Certification Statement Template.pdf
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- Solicitation number
- W52P1J19RSAWS
About this file
This document contains details for a federal solicitation seeking Special Ammunition and Weapon Systems. The U.S. Army Contracting Command-Rock Island is soliciting proposals for the procurement of Special Ammunition and Weapon Systems on behalf of the U.S. Army, Product Director Special Ammunition and Weapon Systems, Joint Munitions Command Security Assistance Directorate, and Tank and Automotive Command Security Assistance Directorate. The solicitation seeks to award multiple Indefinite Delivery Indefinite Quantity contracts for a variety of ammunition and mortar weapon systems for the Department of Defense, other U.S. agencies, and foreign allies over five one-year ordering periods. Offerors must submit fixed pricing for all required line items by November 13, 2020. The minimum order obligation for each awardee is $20,000 and the maximum quantity of items to be ordered over the life of the contract is 4,103,000,000.
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IICS Control No: Date of Execution:
Item Information and Certification Statement (For CONUS Block 1 and OCONUS Block 1, 2 & 3 Required)
Mark For:
Prime Contractor Name:
Address: Ship to Address:
Phone Number:
Prime Contract
Contract Line Item #
Point of Embarkation:
Item Description: Shipment #:
Shipment
Bill of Lading #:
Total # of
Year of Manufacturer:
Transportation Control # LOT #'s:
(TCN): FMS Case Identifier:
Supplier
Check Box:
Tech. Data Pkg./Eng. Change Pkg. Approval Date:
GROUND
LAT Concurrence Date:
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1) Acknowledgement of visual inspection at source on behalf of the U.S. Government:
USG Representative (printed/stamped) Title and Contact Number
Date Signature of USG Representative
2) Acknowledgement of receipt of the items on behalf of the U.S. Government and assumption of full responsibility for movement from this point forward:
USG Receiving Official (printed/stamped) Title and Contact Number
Signature of USG Receiving Official Date
3) Acknowledgement of visual inspection, which includes kind, count, and condition of the packaging, marking, and palletization of the items on behalf of the U.S. Government:
USG Receiving Official (printed/stamped) Title and Contact Number
Signature of USG Receiving Official Date
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DATE
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AIR
DATE
DATE
SEA
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