Attachment 3- SF 1413 Sub-Contractor Form.pdf

OMB Control No. 2120-0595 (SF-1413) FAA Template No. 21 (8/97)

STATEMENT AND ACKNOWLEDGMENT

PART I - STATEMENT OF PRIME CONTRACTOR

1. PRIME CONTRACT NO.

2. DATE SUBCONTRACT

AWARDED

3. SUBCONTRACT NUMBER

4. PRIME CONTRACTOR (Name, address and ZIP code)

5. SUBCONTRACTOR (Name, address and ZIP code)

6. The prime contractor states that under the contract shown in Item 1, a subcontract was awarded on date shown in Item 2 by

(Name of Awarding Firm) to the subcontractor identified in Item 5, for the following work:

7. PROJECT

8. LOCATION

9. NAME AND TITLE OF PERSON SIGNING

10. BY (Signature)

11. DATE SIGNED

PART II - ACKNOWLEDGMENT OF SUBCONTRACTOR

12. The subcontractor acknowledges that the following clauses of the contract shown in Item 1 are included in this subcontract

Contract Work Hours and Safety

Standards Act - Overtime

Compensation

Payrolls and Basic Records

Withholding of Funds

Disputes Concerning Labor Standards

Other:

Davis-Bacon Act

Apprentices and Trainees

Anti-Kickback Procedures

Subcontracts

Contract Termination

Certification of Eligibility

13. NAME(S) OF ANY INTERMEDIATE SUBCONTRACTORS, IF ANY

14. NAME AND TITLE OF PERSON SIGNING

15. BY (Signature)

16. DATE SIGNED