Exhibit B Contractor's Equipment List.pdf
PDF 249 KB Posted
- Attached to
- Master Agreement AZ|CTR078757
- Contract number
- CTR078757
- Issued by
- Arizona
About this file
Form FES-1000AFORFF is an equipment inventory control form issued by the Arizona Department of Economic Security (DES) to facilitate tracking of capital and stewardship equipment purchased with Department contract funds. The form serves as an official record-keeping document for contractors engaged with DES under state and local contracts.
The form requires contractors to report all equipment acquisitions within 30 days of purchase and annually thereafter until contract termination, with a final end-of-contract inventory submission required at contract conclusion. Contractors must provide detailed information for each equipment item, including item description and model number, manufacturer and serial number, acquisition date, physical location (excluding P.O. Box addresses), total item cost, and the amount of contract funds used for acquisition. All information must be typed, and the form must be signed by the individual with delegated authority for inventory control. The contractor submits completed forms to the DES Program Division/Administration Contract Unit. The form includes standard equal opportunity employment and non-discrimination disclosures under the Civil Rights Act of 1964, Americans with Disabilities Act of 1990, Section 504 of the Rehabilitation Act of 1973, Age Discrimination Act of 1975, and the Genetic Information Nondiscrimination Act of 2008.
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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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