Exhibit B Contractor's Equipment List.pdf
PDF 249 KB Posted
- Attached to
- Master Agreement AZ|CTR078755
- Contract number
- CTR078755
- Issued by
- Arizona
About this file
Document Summary
FES-1000AFORFF is a Contractor's Equipment List form issued by the Arizona Department of Economic Security (DES). This document serves as an inventory control tool for capital and stewardship equipment purchased with departmental contract funds. The form is designed to track equipment acquired by contractors throughout the contract period and upon contract conclusion.
Contractors must complete and submit the equipment list within 30 days of acquiring any equipment purchased with contract funds and annually thereafter until contract termination. The form requires documentation of specific details for each equipment item, including item description with model number, manufacturer and serial number, acquisition date, physical location (street address only, not P.O. Box), total item cost, and the amount of contract funds used to acquire the item. All information must be typed and submitted to the DES Program Division/Administration Contract Unit. The form captures contractor identification information (legal name, DBA, FEI/SSN, contact details), contract specifics (contract number, begin and end dates), and requires authorized contractor signature. An end-of-contract inventory submission is required upon contract conclusion. The document includes standard equal opportunity and non-discrimination compliance language covering civil rights protections and reasonable accommodations for individuals with disabilities.
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Text version
FES-1000AFORFF (1-16) ARIZONA DEPARTMENT OF ECONOMIC SECURITY
☐ Contract Inception
☐ Annual Inventory
☐ End-of-Contract Inventory
CONTRACTOR’S EQUIPMENT LIST
(Capital and Stewardship Equipment Items) Page ______ of ______
CONTRACTOR’S NAME(Legal name and DBA “doing businessas” 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
EXHIBIT B
CONTRACTOR’S NAME(Printed) TITLE
CONTRACTOR’S SIGNATURE DATE SIGNED
DES CONTRACT NOTICES PERSON’S NAME(Printed) DES CONTRACT NOTICES PERSON’S SIGNATURE 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.
Thefollowingsectionsmustbecompletedbythecontractorwithin30daysofacquisitionofequipmentpurchasedwithcontractfundsandannuallythereafter 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(doingbusiness as)name.
FEI OR SSN. Enter the federal employer identificationnumber or social security number as applicable.
DES CONTRACT NO. Enter the contract number throughwhich the equipment was purchased or acquired.
INVENTORY DATE. Enter the date form is prepared.
ITEM DESCRIPTION. Enter the type of item and modelnumber.
ACQUISITION DATE. Enter the acquisition date ofpurchased equipment item.
PHYSICAL LOCATION. Enter the address where the equipmentis located. Do not use a “P.O. Box” designation.
TOTAL ITEM COST. Enter the total cost of the equipmentitem.
DES CONTRACT COST. Enter the amount of contractfunds used to acquire the item.
CONTRACTOR’S SIGNATURE. The individual delegatedauthority 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.
EqualOpportunityEmployer/Program•UnderTitlesVIandVIIoftheCivilRightsActof1964(TitleVI&VII),andtheAmericanswithDisabilitiesActof1990(ADA),Section 504 of the Rehabilitation Act of 1973, the Age Discrimination Act of 1975, and Title II of theGeneticInformationNondiscriminationAct(GINA)of2008;theDepartment prohibitsdiscriminationinadmissions,programs,services,activities,oremploymentbasedonrace,color,religion,sex,nationalorigin,age,disability,geneticsandretaliation.The Department must make areasonableaccommodationtoallowapersonwithadisabilitytotakepartinaprogram,serviceoractivity.Forexample,thismeansifnecessary,the Departmentmustprovidesignlanguageinterpretersforpeoplewhoaredeaf,awheelchairaccessiblelocation,orenlargedprintmaterials.ItalsomeansthattheDepartmentwill takeanyotherreasonableactionthatallowsyoutotakepartinandunderstandaprogramoractivity,includingmakingreasonablechangestoanactivity.Ifyoubelievethatyou willnotbeabletounderstandortakepartinaprogramoractivitybecauseofyourdisability,pleaseletusknowofyourdisabilityneedsinadvanceifatallpossible.Torequestthis document in alternativeformatorforfurtherinformationaboutthispolicy,contactyourlocaloffice;TTY/TDDServices:7-1-1.•FreelanguageassistanceforDESservicesis available upon request. • Ayuda gratuita con traducciones relacionadas con los servicios del DES está disponible a solicitud del cliente.
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