Exhibit_A_-_Contractor_s_Equipment_List.doc
DOC document 114 KB Posted
- Attached to
- Master Agreement AZ|CTR075474
- Contract number
- CTR075474
- Issued by
- Arizona
About this file
This document is a Contractor's Equipment List (FES-1000AFORFF) form used by the Arizona Department of Economic Security (DES) for inventory control of capital and stewardship equipment purchased with contract funds. The form is designed to track equipment items acquired through a specific contract, requiring contractors to document detailed information about equipment including manufacturer, serial number, acquisition date, physical location, total item cost, and the portion of cost covered by the DES contract.
The form mandates that contractors complete and submit the equipment inventory within 30 days of acquiring an item and annually thereafter, with a final inventory at contract conclusion. Contractors must provide their legal business name, federal identification number, contract number, and a physical location for each equipment item. The document emphasizes precise documentation and requires an original signature from the authorized individual responsible for inventory control. Submission is to be made to the DES Program Division/Administration Contract Unit, with the form serving as a comprehensive tracking mechanism for equipment purchased using departmental contract funds.
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Text version
FES-1000AFORFF (1-16)
ARIZONA DEPARTMENT OF ECONOMIC SECURITY
FORMCHECKBOX
Contract Inception
FORMCHECKBOX
Annual Inventory
FORMCHECKBOX
End-of-Contract Inventory
CONTRACTOR’S EQUIPMENT LIST
(Capital and Stewardship Equipment Items) Page ______ of ______
CONTRACTOR’S NAME (Legal name and DBA “doing business as” name)
FEI/SSN
MAILING ADDRESS (P.O. Box or No., Street, City, State, ZIP)
PHONE NO.
DES CONTRACT NO.
CONTRACT BEGIN DATE
CONTRACT END DATE
INVENTORY DATE
| Item Description |
| Manufacturer |
| Serial No. |
| Acqu. |
Date
| Physical Location |
| Total |
Item Cost
DES
Contract Cost
CONTRACTOR’S NAME (Printed)
TITLE
CONTRACTOR’S SIGNATURE
Original Signature Required!
DATE SIGNED
DES CONTRACT NOTICES PERSON’S NAME (Printed)
DES CONTRACT NOTICES PERSON’S SIGNATURE
Original Signature Required!
PHONE NO.
DES PROGRAM
MAIL DROP
DATE SIGNED
See reverse for EOE/ADA/LEP/GINA disclosures.
Completion Instructions for FES-1000AFORFF
CONTRACTOR’S EQUIPMENT LIST
(Capital and Stewardship Equipment Items)
A. Purpose.
To facilitate the inventory control of capital and stewardship equipment purchased with Department contract funds.
B. Completion.
The following sections must be completed by the contractor within 30 days of acquisition of equipment purchased with contract funds and annually thereafter until the contract’s termination. At the contract’s conclusion date, an end-of-contract inventory is completed. ALL INFORMATION IS TO BE TYPED.
All items are self-explanatory except:
CONTRACTOR’S NAME. Enter legal name and DBA (doing business as) name.
FEI OR SSN. Enter the federal employer identification number or social security number as applicable.
DES CONTRACT NO. Enter the contract number through which the equipment was purchased or acquired.
INVENTORY DATE. Enter the date form is prepared.
ITEM DESCRIPTION. Enter the type of item and model number.
ACQUISITION DATE. Enter the acquisition date of purchased equipment item.
PHYSICAL LOCATION. Enter the address where the equipment is located. Do not use a “P.O. Box” designation.
TOTAL ITEM COST. Enter the total cost of the equipment item.
DES CONTRACT COST. Enter the amount of contract funds used to acquire the item.
CONTRACTOR’S SIGNATURE. The individual delegated authority for the inventory control must sign the form.
Shaded area is to be completed by DES staff.
C. Routing.
The contractor submits the form to the DES Program Division/Administration Contract Unit within 30 days of the acquisition of the item and annually thereafter.
Equal Opportunity Employer/Program • Under Titles VI and VII of the Civil Rights Act of 1964 (Title VI & VII), and the Americans with Disabilities Act of 1990 (ADA), Section 504 of the Rehabilitation Act of 1973, the Age Discrimination Act of 1975, and Title II of the Genetic Information Nondiscrimination Act (GINA) of 2008; the Department prohibits discrimination in admissions, programs, services, activities, or employment based on race, color, religion, sex, national origin, age, disability, genetics and retaliation. The Department must make a reasonable accommodation to allow a person with a disability to take part in a program, service or activity. For example, this means if necessary, the Department must provide sign language interpreters for people who are deaf, a wheelchair accessible location, or enlarged print materials. It also means that the Department will take any other reasonable action that allows you to take part in and understand a program or activity, including making reasonable changes to an activity. If you believe that you will not be able to understand or take part in a program or activity because of your disability, please let us know of your disability needs in advance if at all possible. To request this document in alternative format or for further information about this policy, contact your local office; TTY/TDD Services: 7-1-1. • Free language assistance for DES services is available upon request. • Ayuda gratuita con traducciones relacionadas con los servicios del DES está disponible a solicitud del cliente.
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