SF1449.pdf

PDF 605 KB Posted Jul 18, 2011

Attached to: FDA Center Submission Tracking and Reporting (CSTAR)
Solicitation number: FDA-SOL-11-1085941
Issued by: Department of Health and Human Services Food and Drug Administration

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SF 1449 Cover Sheet

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EPLC_SLA_MOU_v . .doc	DOC document	Jul 18, 2011
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SOLICITATION/CONTRACT/ORDER FOR COMMERCIAL ITEMS

OFFEROR TO COMPLETE BLOCKS 12, 17, 23, 24, & 30

1. REQUISITION NUMBER PAGE 1 OF

2. CONTRACT NO. 3. AWARD/EFFECTIVE

DATE

4. ORDER NUMBER 5. SOLICITATION NUMBER 6. SOLICITATION ISSUE

DATE

7. FOR SOLICITATION

INFORMATION CALL:

a. NAME b. TELEPHONE NUMBER (No collect calls)

8. OFFER DUE DATE/

LOCAL TIME

9. ISSUED BY

13b. RATING

14. METHOD OF SOLICITATION

CODE

15. DELIVER TO 16. ADMINISTERED BY CODE

18a. PAYMENT WILL BE MADE BY CODE17a. CONTRACTOR/

OFFEROR

CODE

FACILITY

CODE

TELEPHONE NO.

17b. CHECK IF REMITTANCE IS DIFFERENT AND PUT SUCH ADDRESS IN

OFFER

18b. SUBMIT INVOICES TO ADDRESS SHOWN IN BLOCK 18a UNLESS BLOCK

BELOW IS CHECKED

RFQ IFB RFP

SEE ADDENDUM

19.

ITEM NO.

20.

SCHEDULE OF SUPPLIES/SERVICES

21.

QUANTITY

22.

UNIT

23.

UNIT PRICE

24.

AMOUNT

(Use Reverse and/or Attach Additional Sheets as Necessary)

25. ACCOUNTING AND APPROPRIATION DATA 26. TOTAL AWARD AMOUNT (For Govt. Use Only)

28. CONTRACTOR IS REQUIRED TO SIGN THIS DOCUMENT AND RETURN

COPIES TO ISSUING OFFICE. CONTRACTOR AGREES TO FURNISH AND

DELIVER ALL ITEMS SET FORTH OR OTHERWISE IDENTIFIED ABOVE AND ON ANY

ADDITIONAL SHEETS SUBJECT TO THE TERMS AND CONDITIONS SPECIFIED

29. AWARD OF CONTRACT: REF. OFFER

DATED . . YOUR OFFER ON SOLICITATION

(BLOCK 5), INCLUDING ANY ADDITIONS OR CHANGES WHICH ARE

SET FORTH HEREIN, IS ACCEPTED AS TO ITEMS:

30a. SIGNATURE OF OFFEROR/CONTRACTOR

30b. NAME AND TITLE OF SIGNER (Type or print) 30c. DATE SIGNED

31a. UNITED STATES OF AMERICA (SIGNATURE OF CONTRACTING OFFICER)

31b. NAME OF CONTRACTING OFFICER (Type or print) 31c. DATE SIGNED

AUTHORIZED FOR LOCAL REPRODUCTION

PREVIOUS EDITION IS NOT USABLE

STANDARD FORM 1449 (REV. 3/2011)

Prescribed by GSA - FAR (48 CFR) 53.212

10. THIS ACQUISITION IS UNRESTRICTED OR

NAICS:

SIZE STANDARD:

13a. THIS CONTRACT IS A

RATED ORDER UNDER

DPAS (15 CFR 700)

SET ASIDE: % FOR:

11. DELIVERY FOR FOB DESTINA-

TION UNLESS BLOCK IS

MARKED

SEE SCHEDULE

12. DISCOUNT TERMS

ARE ARE NOT ATTACHED

27a. SOLICITATION INCORPORATES BY REFERENCE FAR 52.212-1, 52.212-4. FAR 52.212-3 AND 52.212-5 ARE ATTACHED. ADDENDA

27b. CONTRACT/PURCHASE ORDER INCORPORATES BY REFERENCE FAR 52.212-4. FAR 52.212-5 IS ATTACHED. ADDENDA

8 (A)

ECONOMICALLY DISADVANTAGED

WOMEN-OWNED SMALL BUSINESS

(EDWOSB)

WOMEN-OWNED SMALL

BUSINESS (WOSB)

SERVICE-DISABLED

VETERAN-OWNED

SMALL BUSINESS

HUBZONE SMALL

BUSINESS

SMALL BUSINESS

STANDARD FORM 1449 (REV. 3/2011) BACK

19.

ITEM NO.

20.

SCHEDULE OF SUPPLIES/SERVICES

21.

QUANTITY

22.

UNIT

23.

UNIT PRICE

24.

AMOUNT

32a. QUANTITY IN COLUMN 21 HAS BEEN

RECEIVED INSPECTED ACCEPTED, AND CONFORMS TO THE CONTRACT, EXCEPT AS NOTED:

41a. I CERTIFY THIS ACCOUNT IS CORRECT AND PROPER FOR PAYMENT

32b. SIGNATURE OF AUTHORIZED GOVERNMENT

REPRESENTATIVE

32c. DATE

41b. SIGNATURE AND TITLE OF CERTIFYING OFFICER 41c. DATE

42a. RECEIVED BY (Print)

42b. RECEIVED AT (Location)

42c. DATE REC'D (YY/MM/DD) 42d. TOTAL CONTAINERS

40. PAID BY

32d. PRINTED NAME AND TITLE OF AUTHORIZED GOVERNMENT

REPRESENTATIVE

32e. MAILING ADDRESS OF AUTHORIZED GOVERNMENT REPRESENTATIVE 32f. TELPHONE NUMBER OF AUTHORZED GOVERNMENT REPRESENTATIVE

32g. E-MAIL OF AUTHORIZED GOVERNMENT REPRESENTATIVE

33. SHIP NUMBER 34. VOUCHER NUMBER 35. AMOUNT VERIFIED

CORRECT FOR

PARTIAL FINAL

37. CHECK NUMBER

38. S/R ACCOUNT NO. 39. S/R VOUCHER NUMBER

36. PAYMENT

COMPLETE PARTIAL FINAL

Printing C:\FORMFLOW\FORMS\SF\S1449_3.FRP BarbMWilliams SOLICITATION/CONTRACT/ORDER FOR COMMERCIAL ITEMS OFFEROR TO COMPLETE BLOCKS 12, 17, 23, 24, & 30

1. REQUISITION NUMBER

PAGE 1 OF

2. CONTRACT NO.

3. AWARD/EFFECTIVE

DATE

4. ORDER NUMBER

5. SOLICITATION NUMBER

6. SOLICITATION ISSUE

DATE

7. FOR SOLICITATION

INFORMATION CALL:

a. NAME

b. TELEPHONE NUMBER (No collect calls)

8. OFFER DUE DATE/

LOCAL TIME

9. ISSUED BY

13b. RATING

14. METHOD OF SOLICITATION

CODE

15. DELIVER TO

16. ADMINISTERED BY

CODE

18a. PAYMENT WILL BE MADE BY

CODE

17a. CONTRACTOR/

OFFEROR

CODE

FACILITY

CODE

TELEPHONE NO.

17b. CHECK IF REMITTANCE IS DIFFERENT AND PUT SUCH ADDRESS IN OFFER 18b. SUBMIT INVOICES TO ADDRESS SHOWN IN BLOCK 18a UNLESS BLOCK BELOW IS CHECKED

RFQ

IFB

RFP

SEE ADDENDUM

19.

ITEM NO.

20.

SCHEDULE OF SUPPLIES/SERVICES

21.

QUANTITY

22.

UNIT

23.

UNIT PRICE

24.

AMOUNT

(Use Reverse and/or Attach Additional Sheets as Necessary)

25. ACCOUNTING AND APPROPRIATION DATA

26. TOTAL AWARD AMOUNT (For Govt. Use Only)

28. CONTRACTOR IS REQUIRED TO SIGN THIS DOCUMENT AND RETURN

COPIES TO ISSUING OFFICE. CONTRACTOR AGREES TO FURNISH AND

DELIVER ALL ITEMS SET FORTH OR OTHERWISE IDENTIFIED ABOVE AND ON ANY

ADDITIONAL SHEETS SUBJECT TO THE TERMS AND CONDITIONS SPECIFIED

29. AWARD OF CONTRACT: REF. OFFER

DATED . . YOUR OFFER ON SOLICITATION

(BLOCK 5), INCLUDING ANY ADDITIONS OR CHANGES WHICH ARE

SET FORTH HEREIN, IS ACCEPTED AS TO ITEMS:

30a. SIGNATURE OF OFFEROR/CONTRACTOR 30b. NAME AND TITLE OF SIGNER (Type or print) 30c. DATE SIGNED 31a. UNITED STATES OF AMERICA (SIGNATURE OF CONTRACTING OFFICER) 31b. NAME OF CONTRACTING OFFICER (Type or print) 31c. DATE SIGNED

AUTHORIZED FOR LOCAL REPRODUCTION

PREVIOUS EDITION IS NOT USABLE

STANDARD FORM 1449 (REV. 3/2011)

Prescribed by GSA - FAR (48 CFR) 53.212

10. THIS ACQUISITION IS

UNRESTRICTED OR

NAICS:

SIZE STANDARD:

13a. THIS CONTRACT IS A RATED ORDER UNDER DPAS (15 CFR 700)

SET ASIDE:

% FOR:

11. DELIVERY FOR FOB DESTINA-

TION UNLESS BLOCK IS

MARKED

SEE SCHEDULE

12. DISCOUNT TERMS

ARE

ARE NOT ATTACHED

ARE

ARE NOT ATTACHED

27a. SOLICITATION INCORPORATES BY REFERENCE FAR 52.212-1, 52.212-4. FAR 52.212-3 AND 52.212-5 ARE ATTACHED. ADDENDA 27b. CONTRACT/PURCHASE ORDER INCORPORATES BY REFERENCE FAR 52.212-4. FAR 52.212-5 IS ATTACHED. ADDENDA \\iaimain\apps1\Pam_Ward\Logos\Pointer.jpg Right Arrow Pointing to Call the Contact Point for this Solicitation/Contract/Order 8 (A)

ECONOMICALLY DISADVANTAGED

WOMEN-OWNED SMALL BUSINESS (EDWOSB)

SMALL BUSINESS

WOMEN-OWNED SMALL

BUSINESS (WOSB)

SMALL BUSINESS

SERVICE-DISABLED

VETERAN-OWNED

SMALL BUSINESS

HUBZONE SMALL

BUSINESS

SMALL BUSINESS

STANDARD FORM 1449 (REV. 3/2011)

BACK

19.

ITEM NO.

20.

SCHEDULE OF SUPPLIES/SERVICES

21.

QUANTITY

22.

UNIT

23.

UNIT PRICE

24.

AMOUNT

32a. QUANTITY IN COLUMN 21 HAS BEEN

RECEIVED

INSPECTED

ACCEPTED, AND CONFORMS TO THE CONTRACT, EXCEPT AS NOTED:

41a. I CERTIFY THIS ACCOUNT IS CORRECT AND PROPER FOR PAYMENT 32b. SIGNATURE OF AUTHORIZED GOVERNMENT

REPRESENTATIVE

32c. DATE 41b. SIGNATURE AND TITLE OF CERTIFYING OFFICER 41c. DATE 42a. RECEIVED BY (Print) 42b. RECEIVED AT (Location) 42c. DATE REC'D (YY/MM/DD) 42d. TOTAL CONTAINERS

40. PAID BY

32d. PRINTED NAME AND TITLE OF AUTHORIZED GOVERNMENT REPRESENTATIVE 32e. MAILING ADDRESS OF AUTHORIZED GOVERNMENT REPRESENTATIVE 32f. TELPHONE NUMBER OF AUTHORZED GOVERNMENT REPRESENTATIVE 32g. E-MAIL OF AUTHORIZED GOVERNMENT REPRESENTATIVE

33. SHIP NUMBER

34. VOUCHER NUMBER

35. AMOUNT VERIFIED

CORRECT FOR

PARTIAL

FINAL

37. CHECK NUMBER

38. S/R ACCOUNT NO.

39. S/R VOUCHER NUMBER

36. PAYMENT

COMPLETE

PARTIAL

FINAL

1. REQUISITION NUMBER:

PAGE 1 OF: 56

2. CONTRACT NUMBER:

4. ORDER NUMBER:

5. SOLICITATION NUMBER: FDA-SOL-11-1085941

7. FOR SOLICITATION INFORMATION CALL: a. NAME: Danielle Pena

7. FOR SOLICITATION INFORMATION CALL: b. TELEPHONE NUMBER (No collect calls):

9. ISSUED BY CODE:

% For : 100

12. DISCOUNT TERMS:

13b. RATING:

15. DELIVER TO:

16. ADMINISTERED BY CODE:

16. ADMINISTERED BY:

17a. CONTRACTOR/ OFFEROR CODE:

17a. CONTRACTOR/ OFFEROR:

17b. CHECK IF REMITTANCE IS DIFFERENT AND PUT SUCH ADDRESS IN OFFER:

18a. PAYMENT WILL BE MADE BY:

19. ITEM NUMBER. Line 1 of 8.:

20. SCHEDULE OF SUPPLIES/ SERVICES:

21. QUANTITY:

22. UNIT:

23. UNIT PRICE:

24. AMOUNT:

19. ITEM NUMBER. Line 2 of 8.:

20. SCHEDULE OF SUPPLIES/ SERVICES:

21. QUANTITY:

22. UNIT:

23. UNIT PRICE:

24. AMOUNT:

19. ITEM NUMBER. Line 3 of 8.:

20. SCHEDULE OF SUPPLIES/ SERVICES: FDA Center Submission Tracking and Reporting (CSTAR)

21. QUANTITY:

22. UNIT:

23. UNIT PRICE:

24. AMOUNT:

19. ITEM NUMBER. Line 4 of 8.:

20. SCHEDULE OF SUPPLIES/ SERVICES: see continuation sheet for complete solicitation.

21. QUANTITY:

22. UNIT:

23. UNIT PRICE:

24. AMOUNT:

19. ITEM NUMBER. Line 5 of 8.:

20. SCHEDULE OF SUPPLIES/ SERVICES:

21. QUANTITY:

22. UNIT:

23. UNIT PRICE:

24. AMOUNT:

19. ITEM NUMBER. Line 6 of 8.:

21. QUANTITY:

22. UNIT:

23. UNIT PRICE:

24. AMOUNT:

19. ITEM NUMBER. Line 7 of 8.:

20. SCHEDULE OF SUPPLIES/ SERVICES: Please be advised that this solicitation is hereby issued

20. SCHEDULE OF SUPPLIES/ SERVICES:

21. QUANTITY:

22. UNIT:

23. UNIT PRICE:

24. AMOUNT:

19. ITEM NUMBER. Line 8 of 8.:

20. SCHEDULE OF SUPPLIES/ SERVICES:

21. QUANTITY:

22. UNIT:

23. UNIT PRICE:

24. AMOUNT:

25. ACCOUNTING AND APPROPRIATION DATA:

28. CONTRACTOR IS REQUIRED TO SIGN THIS DOCUMENT AND RETURN COPIES TO ISSUING OFFICE. CONTRACTOR AGREES TO FURNISH AND DELIVER ALL ITEMS SET FORTH OR OTHERWISE IDENTIFIED ABOVE AND ON ANY

ADDITIONAL SHEETS SUBJECT TO THE TERMS AND CONDITIONS SPECIFIED. INITIALS :

29. AWARD OF CONTRACT: REFERENCE OFFER:

DATE. YOUR OFFER ON SOLICITATION

(BLOCK 5), INCLUDING ANY ADDITIONS OR CHANGES WHICH ARE

SET FORTH HEREIN, IS ACCEPTED AS TO ITEMS.:

30b. NAME OF SIGNER (Type or print):

30b. TITLE OF SIGNER (Type or print):

31b. NAME OF CONTRACTING OFFICER (Type or print):

10. THIS ACQUISITION IS UNRESTRICTED: 0

10. THIS ACQUISITION IS SET ASIDE:: 1

11. DELIVERY FOR FOB DESTINATION UNLESS BLOCK IS MARKED SEE SCHEDULE: 0

13a. THIS CONTRACT IS A RATED ORDER UNDER DPAS (15 CFR 700): 0

14. METHOD OF SOLICITATION RFQ: 0

10. THIS ACQUISITION IS NAICS:: 541511

10. THIS ACQUISITION IS SIZE STANDARD:: $25.0M

14. METHOD OF SOLICITATION IFB: 0

14. METHOD OF SOLICITATION RFP: 1

18a. PAYMENT WILL BE MADE BY CODE:

29. AWARD OF CONTRACT : 1

29. AWARD OF CONTRACT : 0

27a. ARE ATTACHED: 1

27a. ARE NOT ATTACHED: 0

27b. ARE ATTACHED: 0

27b. ARE NOT ATTACHED: 0

42c. DATE RECEIVED. Enter 2 digit month, 2 digit day and 4 digit year.: 2011-07-18

42c. DATE RECEIVED. Enter 2 digit month, 2 digit day and 4 digit year.: 2011-08-08

3. AWARD/ EFFECTIVE DATE. Enter 2 digit month, 2 digit day and 4 digit year.:

18b. SUBMIT INVOICES TO ADDRESS SHOWN IN BLOCK 18a UNLESS BLOCK IS CHECKED SEE ADDENDUM: 0

26. TOTAL AWARD AMOUNT (FOR GOVT. USE ONLY):

17b. CHECK IF REMITTANCE IS DIFFERENT AND PUT SUCH ADDRESS IN

OFFER : 0

41b. SIGNATURE OF CERTIFYING OFFICER. :

10. THIS ACQUISITION IS 8 (A): 1

10. THIS ACQUISITION IS SMALL BUSINESS: 0

10. THIS ACQUISITION IS SERVICE-DISABLED VETERAN-OWNED SMALL BUSINESS: 0

10. THIS ACQUISITION IS HUBZONE SMALL BUSINESS: 0

19. ITEM NUMBER. Line 1 of 28.:

20. SCHEDULE OF SUPPLIES/SERVICES:

21. QUANTITY:

22. UNIT:

23. UNIT PRICE:

24. AMOUNT:

19. ITEM NUMBER. Line 2 of 28.:

20. SCHEDULE OF SUPPLIES/SERVICES: under FAR 52.232-18, Availability of Funds clause,

21. QUANTITY:

22. UNIT:

23. UNIT PRICE:

24. AMOUNT:

19. ITEM NUMBER. Line 3 of 28.:

20. SCHEDULE OF SUPPLIES/SERVICES: which states:

21. QUANTITY:

22. UNIT:

23. UNIT PRICE:

24. AMOUNT:

19. ITEM NUMBER. Line 4 of 28.:

20. SCHEDULE OF SUPPLIES/SERVICES:

21. QUANTITY:

22. UNIT:

23. UNIT PRICE:

24. AMOUNT:

19. ITEM NUMBER. Line 5 of 28.:

21. QUANTITY:

22. UNIT:

23. UNIT PRICE:

24. AMOUNT:

19. ITEM NUMBER. Line 6 f 28.:

20. SCHEDULE OF SUPPLIES/SERVICES: "Funds are not presently available for this contract. The

20. SCHEDULE OF SUPPLIES/SERVICES: Government's obligation under this contract is

21. QUANTITY:

22. UNIT:

23. UNIT PRICE:

24. AMOUNT:

19. ITEM NUMBER. Line 7 of 28.:

20. SCHEDULE OF SUPPLIES/SERVICES: contingent upon the availability of appropriated funds

21. QUANTITY:

22. UNIT:

23. UNIT PRICE:

24. AMOUNT:

20. SCHEDULE OF SUPPLIES/SERVICES: from which payment for contract purposes can be

21. QUANTITY:

22. UNIT:

24. AMOUNT:

19. ITEM NUMBER. Line 8 of 28.:

19. ITEM NUMBER. Line 9 of 28.:

20. SCHEDULE OF SUPPLIES/SERVICES: made. No legal liability on the part of the Government

21. QUANTITY:

22. UNIT:

23. UNIT PRICE:

24. AMOUNT:

19. ITEM NUMBER. Line 10 of 28.:

20. SCHEDULE OF SUPPLIES/SERVICES: for any payment may arise until funds are made

21. QUANTITY:

22. UNIT:

23. UNIT PRICE:

24. AMOUNT:

19. ITEM NUMBER. Line 11 of 28.:

20. SCHEDULE OF SUPPLIES/SERVICES: available to the Contracting Officer for this contract

21. QUANTITY:

22. UNIT:

23. UNIT PRICE:

24. AMOUNT:

19. ITEM NUMBER. Line 12 of 28.:

20. SCHEDULE OF SUPPLIES/SERVICES: and until the Contractor receives notice of such

21. QUANTITY:

22. UNIT:

23. UNIT PRICE:

24. AMOUNT:

19. ITEM NUMBER. Line 13 of 28.:

20. SCHEDULE OF SUPPLIES/SERVICES: availability, to be confirmed in writing by the

21. QUANTITY:

22. UNIT:

23. UNIT PRICE:

24. AMOUNT:

19. ITEM NUMBER. Line14 of 28.:

20. SCHEDULE OF SUPPLIES/SERVICES: Contracting Officer.

21. QUANTITY:

22. UNIT:

23. UNIT PRICE:

24. AMOUNT:

19. ITEM NUMBER. Line 15 of 28.:

20. SCHEDULE OF SUPPLIES/SERVICES:

21. QUANTITY:

22. UNIT:

23. UNIT PRICE:

24. AMOUNT:

19. ITEM NUMBER. Line 16 of 28.:

20. SCHEDULE OF SUPPLIES/SERVICES:

21. QUANTITY:

22. UNIT:

23. UNIT PRICE:

24. AMOUNT:

19. ITEM NUMBER. Line 17 of 28.:

20. SCHEDULE OF SUPPLIES/SERVICES:

21. QUANTITY:

22. UNIT:

23. UNIT PRICE:

24. AMOUNT:

19. ITEM NUMBER. Line 18 of 28.:

20. SCHEDULE OF SUPPLIES/SERVICES:

21. QUANTITY:

22. UNIT:

23. UNIT PRICE:

24. AMOUNT:

19. ITEM NUMBER. Line 19 of 28.:

20. SCHEDULE OF SUPPLIES/SERVICES:

21. QUANTITY:

22. UNIT:

23. UNIT PRICE:

24. AMOUNT:

19. ITEM NUMBER. Line 20 of 28.:

20. SCHEDULE OF SUPPLIES/SERVICES:

21. QUANTITY:

22. UNIT:

23. UNIT PRICE:

24. AMOUNT:

19. ITEM NUMBER. Line 21 of 28.:

20. SCHEDULE OF SUPPLIES/SERVICES:

21. QUANTITY:

22. UNIT:

23. UNIT PRICE:

24. AMOUNT:

19. ITEM NUMBER. Line 22 of 28.:

20. SCHEDULE OF SUPPLIES/SERVICES:

21. QUANTITY:

22. UNIT:

23. UNIT PRICE:

24. AMOUNT:

19. ITEM NUMBER. Line 23 of 28.:

20. SCHEDULE OF SUPPLIES/SERVICES:

21. QUANTITY:

22. UNIT:

23. UNIT PRICE:

24. AMOUNT:

19. ITEM NUMBER. Line 24 of 28.:

20. SCHEDULE OF SUPPLIES/SERVICES:

21. QUANTITY:

22. UNIT:

23. UNIT PRICE:

24. AMOUNT:

19. ITEM NUMBER. Line 25 of 28.:

20. SCHEDULE OF SUPPLIES/SERVICES:

21. QUANTITY:

22. UNIT:

23. UNIT PRICE:

24. AMOUNT:

19. ITEM NUMBER. Line 26 of 28.:

20. SCHEDULE OF SUPPLIES/SERVICES:

21. QUANTITY:

22. UNIT:

23. UNIT PRICE:

24. AMOUNT:

19. ITEM NUMBER. Line 27 of 28.:

20. SCHEDULE OF SUPPLIES/SERVICES:

21. QUANTITY:

22. UNIT:

23. UNIT PRICE:

24. AMOUNT:

19. ITEM NUMBER. Line 28 of 28.:

20. SCHEDULE OF SUPPLIES/SERVICES:

21. QUANTITY:

22. UNIT:

23. UNIT PRICE:

24. AMOUNT:

32a. QUANTITY IN COLUMN 21 HAS BEEN ACCEPTED, AND CONFORMS TO THE CONTRACT, EXCEPT AS NOTED:

32d. PRINTED NAME OF AUTHORIZED GOVERNMENT REPRESENTATIVE:

32d. PRINTED TITLE OF AUTHORIZED GOVERNMENT REPRESENTATIVE.:

32e. MAILING ADDRESS OF AUTHORIZED GOVERNMENT REPRESENTATIVE:

32F. TELEPHONE NUMBER OF AUTHORIZED GOVERNMENT REPRESENTATIVE:

32G. E-MAIL OF AUTHORIZED GOVERNMENT REPRESENTATIVE:

33. SHIP NUMBER:

34. VOUCHER NUMBER:

35. AMOUNT VERIFIED CORRECT FOR:

37. CHECK NUMBER:

38. S/R ACCOUNT NUMBER:

39. S/R VOUCHER NUMBER:

40. PAID BY:

41b. TITLE OF CERTIFYING OFFICER:

42a. RECEIVED BY (Print):

42b. RECEIVED AT (Location):

42d. TOTAL CONTAINERS:

32a. QUANTITY IN COLUMN 21 HAS BEEN RECEIVED: 0

32a. QUANTITY IN COLUMN 21 HAS BEEN INSPECTED : 0

32a. QUANTITY IN COLUMN 21 HAS BEEN ACCEPTED, AND CONFORMS TO THE CONTRACT, EXCEPT AS NOTED: 0

41c. DATE. Enter 2 digit month, 2 digit day and 4 digit year.:

33. SHIP NUMBER PARTIAL: 0

33. SHIP NUMBER FINAL: 0

32c. DATE. Enter 2 digit month, 2 digit day and 4 digit year.:

36. PAYMENT COMPLETE: 0

36. PAYMENT PARTIAL: 0

36. PAYMENT FINAL: 0

41b. SIGNATURE OF CERTIFYING OFFICER. THIS IS A PROTECTED FIELD.:

File details come from the government source that posted it. Updated Nov 14, 2017.