B08 - Attachment G - Release of Claims.pdf
PDF 992 KB Posted
- Attached to
- IL-CRAB ORCHARD DAM SPILLWAY CONCRETE REPAIRS
- Solicitation number
- 140F0921R0005
About this file
This document is a release of claims form to be signed by a contractor upon completion of a contract with the federal government. The form releases the United States from any claims arising from the contract except those specifically listed by the contractor. It includes fields for the contractor signature and seal, witness signature, contract number, date, and contractor information.
The related federal opportunity is a solicitation from the Department of the Interior Fish and Wildlife Service Region 9 Headquarters for concrete repairs to the spillway at Crab Orchard Dam in Illinois. The solicitation includes the number, name, type of opportunity, and brief description. No further details are provided on requirements, pricing, or response deadlines.
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Text version
RELEASE OF CLAIMS
The undersigned contractor, pursuant to the terms of Contract Number located at hereby release the United States from any and all claims arising under or by virtue of said contract or any modification or change thereof except as follows: (Here list any claims against the Government and the amounts thereof. If none, so state.)
Witness the signature and seal of the undersigned this day of
CONTRACTOR
WITNESS:
(Seal)
(Print or type)
(Signature)
(Official Title)
(Signature)
(Address)
GSA 1142 (REV. 5/2015)
between the United States of America and said contractor for the
GENERAL SERVICES ADMINISTRATION
OMB Control Number: 3090-0080 Expiration Date: 9/30/2021
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 3090-0080. We estimate that it will take 6 minutes 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.
RELEASE OF CLAIMS
The undersigned contractor, pursuant to the terms of Contract Number located at hereby release the United States from any and all claims arising under or by virtue of said contract or any modification or change thereof except as follows: (Here list any claims against the Government and the amounts thereof. If none, so state.)
Witness the signature and seal of the undersigned this day of
CONTRACTOR
WITNESS:
(Seal) (Print or type) (Signature) (Official Title) (Signature) (Address)
GSA 1142 (REV. 5/2015)
between the United States of America and said contractor for the
GENERAL SERVICES ADMINISTRATION
OMB Control Number: 3090-0080 Expiration Date: 9/30/2021 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 3090-0080. We estimate that it will take 6 minutes 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.
| HERE LIST ANY CLAIMS AGAINST THE GOVERNMENT AND THE AMOUNT THEREOF. IF NONE, SO STATE: |
| THE UNDERSIGNED CONTRACTOR, PURSUANT TO THE TERMS OF CONTRACT NUMBER: |
| BETWEEN THE UNITED STATES OF AMERICAN AND SAID CONTRACTOR FOR THE (LINE 1 OF 2): |
| BETWEEN THE UNITED STATES OF AMERICA AND SAID CONTRACTOR FOR THE (LINE 2 OF 2): |
| LOCATED AT: |
| WITNESS THE SIGNATURE AND SEAL OF THE UNDERSIGNED THIS: |
| DAY OF (LINE 1 OF 2): |
| DAY OF (LINE 2 OF 2): |
| WITNESS SIGNATURE. THIS IS A PROTECTED FIELD.: |
| CONTRACTOR SIGNATURE. THIS IS A PROTECTED FIELD.: |
| CONTRACTOR PRINT OR TYPE: |
| WITNESS ADDRESS: |
| CONTRACTOR OFFICIAL TITLE: |
| CONTRACTOR SIGNATURE. THIS IS A PROTECTED FIELD.: |
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