DD1423_21Q0136.doc

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CONTRACT DATA REQUIREMENTS LIST

(1 Data Item) Form Approved

OMB No. 0704-0188

The public reporting burden for this collection of information is estimated to average 110 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing the burden, to the Department of Defense, Executive Services and Communications Directorate (0704-1088). Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number. Please do not return your form to the above organization. Send completed form to the Government Issuing Contracting Officer for the Contract/PR No. Listed in Block E.

A. CONTRACT LINE ITEM NO.

B. EXHIBIT

A

C. CATEGORY:

TDP_____ TM ______ OTHER: MISC

D. SYSTEM/ITEM

EOS Maintenance

E. CONTRACT/PR NO.

0011622162

F. CONTRACTOR

Philips Corporation

1. DATA ITEM NO.

2. TITLE OF DATA ITEM

Facilities Maintenance Report

3. SUBTITLE

Maintenance Report

4. AUTHORITY (Data Acquisition Document No.)

DI-MISC-81423A

5. CONTRACT REFERENCE

C.4.1

6. REQUIRING OFFICE

To Be Provided At Time of Award

7. DD 250 REQ

LT

9. DIST STATEMENT

REQUIRED

A

10. FREQUENCY

ASREQ

12. DATE OF FIRST SUBMISSION

SEE BLK 16

14.

DISTRIBUTION

8. APP CODE

N/A

11. AS OF DATE

SEE BLK 16

13. DATE OF SUBSEQUENT

SUBMISSION

SEE BLK 16

16. REMARKS

BLK 4: REPORTS SHALL BE DELIVERED ELECTRONICALLY IN A MEDIA SELECTED BY

THE GOVERNMENT AT TIME OF DELIVERY. MEDIA TYPES WHICH CAN BE ACCEPTED

INCLUDE FTP, CR-ROM & EMAIL.

BLK 11, 12 AND 13: CONTRACTOR SHALL SUBMIT THE MAINTENANCE REPORT DETAILING ALL WORK ACCOMPLISHED NO LATER THAN (NLT) THIRTY DAYS AFTER EACH SERVICE VISIT.

THIS FACILITIES MAINTENANCE REPORT SHALL BE SENT TO:

UNITED STATES ARMY RESEARCH LABORATORY

To Be Provided At Time of Award

15. TOTAL

G. PREPARED BY

To Be Provided At Time of Award

H. DATE

4 May 2021

I. APPROVED BY

Ariel Amey

J. DATE

4 May 2021

DD FORM 1423-1, FEB 2001

PREVIOUS EDITION MAY BE USED.

Page of Pages

EXHIBIT A – ATTACHMENT 1

ARMY RESEARCH LABORATORY

Report Title Goes Here

Any Subtitles Go Here

By Some Author and Another Author

Month XXXX

Prepared by

Whatever Technology Corporation

0000 Research Drive

Anywhere, ST 20006-1000

Under contract

W911QX-XX-C-XXXX

DISTRIBUTION STATEMENT GOES HERE

EXHIBIT A – ATTACHMENT 2

The findings in this report are not to be construed as an official Department of the Army position unless so designated by other authorized documents.

Citation of manufacturer's or trade names does not constitute an official endorsement or approval of the use thereof.

DESTRUCTION NOTICE: For classified documents, follow the procedures in DoD 5220.22-M, National Industrial Security Program Operating Manual, Chapter 5, Section 7. For unclassified, limited documents, destroy by any method that will prevent disclosure of contents or reconstruction of the document.