.11 Confirmation of Service Form (OS-501) SAMPLE.pdf
PDF 174 KB Posted
- Attached to
- Tree Trimming & Stump Removal Services
- Solicitation number
- 6100065367
- Issued by
- Fulton County, Pennsylvania
About this file
Summary of Confirmation of Service Form (OS-501)
This document is a Confirmation of Service Form used by the Pennsylvania Department of Transportation (PennDOT) to verify and authorize payment for tree trimming and stump removal services rendered within Greene County. The form captures essential service delivery information including the vendor name, contact details, SAP vendor number, and purchase order reference number. It provides line-item detail fields for documenting the description or product ID, quantity, unit of measure, unit price, and item total for services performed. The form requires documentation of the date(s) service was rendered and includes a continuation section for multiple pages to accommodate various line items and service details.
The form operates as part of PennDOT's internal approval and payment authorization workflow. A project manager must certify that services were received satisfactorily and approve payment, while the SRM/R3 receiver must confirm that a goods receipt has been entered in the SAP system within 48 hours of receipt, in compliance with Management Directive 310.31. The vendor provides a signature and date to acknowledge submission. The form includes running totals for page one, page two, and a grand total to consolidate all service charges, with all amounts initially set at $0.00 in the sample version provided.
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Text version
CONFIRMATION OF SERVICE
www.penndot.gov
Date(s) Service Rendered:________________ - _______________ Vendor Name: __________________________________________ Phone: ________________________________________________
PURCHASE ORDER #:___________________________________
SAP Vendor Number:_____________________________________ Address (1): ____________________________________________ Address (2): ____________________________________________ City: ____________________ State: _______ Zip Code: ________
(Reference line items on purchase order that match the services that were performed.)
PO Line # Description / Product ID Quantity U.O.M. Unit Price Item Total
PENNDOT USE ONLY
I certify the services represented by the confirmation of service form above were received satisfactorily. Therefore, I approve payment be made.
Project Manager Signature Date (mm/dd/yyyy)
I certify that I have entered a Goods Receipt in SAP for this service. This should occur within 48 hours of receipt (per Management Directive 310.31).
SRM/R3 Receiver Signature Date (mm/dd/yyyy) SRM Confirmation # / R3 Material Document #
Vendor Signature:_______________________________________________________________ Date:__________________________
Total of Page 1
Total of Page 2
Grand Total
Continued on page 2
$ 0.00 $ 0.00 $ 0.00 $ 0.00 $ 0.00 $ 0.00 $ 0.00 $ 0.00 $ 0.00 $ 0.00 $ 0.00 $ 0.00 $ 0.00 $ 0.00 $ 0.00 $ 0.00 $ 0.00 $ 0.00 $ 0.00 $ 0.00 $ 0.00 $ 0.00 $ 0.00 $ 0.00 $ 0.00 $ 0.00 $ 0.00 $ 0.00
Tree Trimming and Stump Removal Service Confirmation of Service Form (0S-501) SAMPLE
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File details come from the government source that posted it. Updated .