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FTC-FAC-70 (9/01)
Contract No. Invoice No. Invoice Date
Delivery Order No. Work Order No.
Total Contract Amount Through Change Order No. Dated
Value of Work Completed
Total of Prior Invoices
Amount of this Invoice
Signature and Title
GOVERNMENT CERTIFICATION OF INVOICE Date
FROM: Contracting Officer's Technical Representative (COTR) THRU: (1) Chief, Design-Construction Branch (FMD/D-CB)
(2) Contracting Officer (PRO/CCB) TO: Budget and Finance Division (BFD/FIN)
CONTRACT WORK CERTIFIED COMPLETE $
LESS: Retention $
Previous Payments $
Other (Deductions) $
Liquid Damages @ $ /day X Days = $
AMOUNT CERTIFIED FOR PAYMENT $
Remarks:
Evaluated
COTR/PM (FMD) Contracting Officer (PRO/CCB) Reviewed
Chief, Design/Construction Branch (FMD)
CONTRACTOR MUST ALSO COMPLETE CERTIFICATION ON REVERSE OR PAYMENT WILL NOT BE MADE
For FLETC Use Only
OFFICIAL DATE OF RECEIPT BY GOVERNMENT
Contractor's Name and Address (As shown on Contract)
CONSTRUCTION CONTRACTOR'S
INVOICE
(Authorized Contractor Representative)
By
Payment Approved
By:By:
Front
SECURITY TRAINING LIST
Company Name:
Contract and/or Task-Delivery-Purchase Order Number:
Subcontract Company Name:
Name
Prime Contractor Employee
(Y/N)
Subcontractor Employee
(Y/N)
Date Report
On Center
Date Of Training
As the authorized representative of (insert company name) concerning Contract Number HSFLxx-xx-x-xxxxx, I hereby certify that the information provided is true and accurate as reported.
Name and Title Date
FTC-FAC-70 (9/01)
Contract No. Invoice No. Invoice Date
Delivery Order No. Work Order No.
Total Contract Amount Through Change Order No. Dated
Value of Work Completed
Total of Prior Invoices
Amount of this Invoice
Signature and Title
GOVERNMENT CERTIFICATION OF INVOICE Date
FROM: Contracting Officer's Technical Representative (COTR) THRU: (1) Chief, Design-Construction Branch (FMD/D-CB)
(2) Contracting Officer (PRO/CCB) TO: Budget and Finance Division (BFD/FIN)
CONTRACT WORK CERTIFIED COMPLETE $
LESS: Retention $
Previous Payments $
Other (Deductions) $
Liquid Damages @ $ /day X Days = $
AMOUNT CERTIFIED FOR PAYMENT $
Remarks:
Evaluated
COTR/PM (FMD) Contracting Officer (PRO/CCB) Reviewed
Chief, Design/Construction Branch (FMD)
CONTRACTOR MUST ALSO COMPLETE CERTIFICATION ON REVERSE OR PAYMENT WILL NOT BE MADE
For FLETC Use Only
OFFICIAL DATE OF RECEIPT BY GOVERNMENT
Contractor's Name and Address (As shown on Contract)
CONSTRUCTION CONTRACTOR'S
INVOICE
(Authorized Contractor Representative)
By
Payment Approved
By:By:
Front
The following format shall be used by the financial institution to confirm an ILC:
[Confirming Financial Institution’s Letterhead or Name and Address]
(Date) _____________
Our Letter of Credit Advice Number _____________
Beneficiary: ___________ [U.S. Government agency]
Issuing Financial Institution: __________________
Issuing Financial Institution’s LC No.: ___________
Gentlemen:
1. We hereby confirm the above indicated Letter of Credit, the original of which is attached, issued by __________ [name of issuing financial institution] for drawings of up to United States dollars ___________/U.S. $_______ and expiring with our close of business on _____________ [the expiration date], or any automatically extended expiration date.
2. Draft(s) drawn under the Letter of Credit and this Confirmation are payable at our office located at ___________________.
3. We hereby undertake to honor sight draft(s) drawn under and presented with the Letter of Credit and this Confirmation at our offices as specified herein.
4. [This paragraph is omitted if used as a bid guarantee, and subsequent paragraphs are renumbered.] It is a condition of this confirmation that it be deemed automatically extended without amendment for one year from the expiration date hereof, or any automatically extended expiration date, unless:
(a) At least 60 days prior to any such expiration date, we shall notify the Contracting Officer, or the transferee and the issuing financial institution, by registered mail or other receipted means of delivery, that we elect not to consider this confirmation extended for any such additional period; or
(b) The issuing financial institution shall have exercised its right to notify you or the transferee, the account party, and ourselves, of its election not to extend the expiration date of the Letter of Credit.
ILC CONFIRMATION
REQUIRED FORMAT FOR FINANCIAL INSTITUTION TO CONFIRM AN
IRREVOCABLE LETTER OF CREDIT
(As stated in FAR 28.228-14 and prescribed in FAR 28.204-4) sbodford
Typewritten Text
5. This confirmation is subject to the Uniform Customs and Practice (UCP) for Documentary Credits, 1993 Revision, International Chamber of Commerce Publication No. 500, and to the extent not inconsistent therewith, to the laws of ________ [state of confirming financial institution].
6. If this confirmation expires during an interruption of business of this financial institution as described in Article 17 of the UCP, we specifically agree to effect payment if this credit is drawn against within 30 days after the resumption of our business.
Sincerely, [Confirming financial institution]
The following format shall be used by the financial institution to confirm an ILC:
[Confirming Financial Institution’s Letterhead or Name and Address]
(Date) _____________
Our Letter of Credit Advice Number _____________
Beneficiary: ___________ [U.S. Government agency]
Issuing Financial Institution: __________________
Issuing Financial Institution’s LC No.: ___________
Gentlemen:
1. We hereby confirm the above indicated Letter of Credit, the original of which is attached, issued by __________ [name of issuing financial institution] for drawings of up to United States dollars ___________/U.S. $_______ and expiring with our close of business on _____________ [the expiration date], or any automatically extended expiration date.
2. Draft(s) drawn under the Letter of Credit and this Confirmation are payable at our office located at ___________________.
3. We hereby undertake to honor sight draft(s) drawn under and presented with the Letter of Credit and this Confirmation at our offices as specified herein.
4. [This paragraph is omitted if used as a bid guarantee, and subsequent paragraphs are renumbered.] It is a condition of this confirmation that it be deemed automatically extended without amendment for one year from the expiration date hereof, or any automatically extended expiration date, unless:
(a) At least 60 days prior to any such expiration date, we shall notify the Contracting Officer, or the transferee and the issuing financial institution, by registered mail or other receipted means of delivery, that we elect not to consider this confirmation extended for any such additional period; or
(b) The issuing financial institution shall have exercised its right to notify you or the transferee, the account party, and ourselves, of its election not to extend the expiration date of the Letter of Credit.
REQUIRED FORMAT FOR FINANCIAL INSTITUTION TO CONFIRM AN
IRREVOCABLE LETTER OF CREDIT
(As stated in FAR 28.228-14 and prescribed in FAR 28.204-4)
5. This confirmation is subject to the Uniform Customs and Practice (UCP) for Documentary extent not inconsistent therewith, to the laws of ________ [state of confirming financial institution].
6. If this confirmation expires during an interruption of business of this financial institution as described in Article 17 of the UCP, we specifically agree to effect payment if this credit is drawn against within 30 days after the resumption of our business.
[Confirming financial institution]
REQUIRED FORMAT FOR IRREVOCABLE LETTER OF CREDIT
(As stated in FAR 52.228-14 and prescribed in FAR 28.204-4)
The following format shall be used by the issuing financial institution to create an ILC:
[Issuing Financial Institution’s Letterhead or Name and Address]
Issue Date ______
Irrevocable Letter of Credit No. ________________
Account party’s name ________________________
Account party’s address ______________________
For Solicitation No. __________ (for reference only)
To: [U.S. Government agency] [U.S. Government Agency’s Address]
1. We hereby establish this irrevocable and transferable Letter of Credit in your favor for one or more drawings up to United States $ ______. This Letter of Credit is payable at [issuing financial institution’s and, if any, confirming financial institution’s] office at [issuing financial institution’s address and, if any, confirming financial institution’s address] and expires with our close of business on ______, or any automatically extended expiration date.
2. We hereby undertake to honor your or the transferee’s sight draft(s) drawn on the issuing or, if any, the confirming financial institution, for all or any part of this credit if presented with this Letter of Credit and confirmation, if any, at the office specified in paragraph 1 of this Letter of Credit on or before the expiration date or any automatically extended expiration date.
3. [This paragraph is omitted if used as a bid guarantee, and subsequent paragraphs are renumbered.] It is a condition of this Letter of Credit that it is deemed to be automatically extended without amendment for one year from the expiration date hereof, or any future expiration date, unless at least 60 days prior to any expiration date, we notify you or the transferee by registered mail, or other receipted means of delivery, that we elect not to consider this Letter of Credit renewed for any such additional period. At the time we notify you, we also agree to notify the account party (and confirming financial institution, if any) by the same means of delivery.
4. This Letter of Credit is transferable. Transfers and assignments of proceeds are to be effected without charge to either the beneficiary or the transferee/assignee of proceeds. Such transfer or assignment shall be only at the written direction of the Government (the beneficiary) in a form satisfactory to the issuing financial institution and the confirming financial institution, if any.
FORMAT IRREVOCABLE LETTER OF CREDIT
5. This Letter of Credit is subject to the Uniform Customs and Practice (UCP) for Documentary extent not inconsistent therewith, to the laws of _____________________ [state of confirming financial institution, if any, otherwise state of issuing financial institution].
6. If this credit expires during an interruption of business of this financial institution as described in Article 17 of the UCP, the financial institution specifically agrees to effect payment if this credit is drawn against within 30 days after the resumption of our business.
[Issuing financial institution]
REQUIRED FORMAT FOR IRREVOCABLE LETTER OF CREDIT
(As stated in FAR 52.228-14 and prescribed in FAR 28.204-4)
The following format shall be used by the issuing financial institution to create an ILC:
[Issuing Financial Institution’s Letterhead or Name and Address]
Issue Date ______
Irrevocable Letter of Credit No. ________________
Account party’s name ________________________
Account party’s address ______________________
For Solicitation No. __________ (for reference only)
To: [U.S. Government agency] [U.S. Government Agency’s Address]
1. We hereby establish this irrevocable and transferable Letter of Credit in your favor for one or more drawings up to United States $ ______. This Letter of Credit is payable at [issuing financial institution’s and, if any, confirming financial institution’s] office at [issuing financial institution’s address and, if any, confirming financial institution’s address] and expires with our close of business on ______, or any automatically extended expiration date.
2. We hereby undertake to honor your or the transferee’s sight draft(s) drawn on the issuing or, if any, the confirming financial institution, for all or any part of this credit if presented with this Letter of Credit and confirmation, if any, at the office specified in paragraph 1 of this Letter of Credit on or before the expiration date or any automatically extended expiration date.
3. [This paragraph is omitted if used as a bid guarantee, and subsequent paragraphs are renumbered.] It is a condition of this Letter of Credit that it is deemed to be automatically extended without amendment for one year from the expiration date hereof, or any future expiration date, unless at least 60 days prior to any expiration date, we notify you or the transferee by registered mail, or other receipted means of delivery, that we elect not to consider this Letter of Credit renewed for any such additional period. At the time we notify you, we also agree to notify the account party (and confirming financial institution, if any) by the same means of delivery.
4. This Letter of Credit is transferable. Transfers and assignments of proceeds are to be effected without charge to either the beneficiary or the transferee/assignee of proceeds. Such transfer or assignment shall be only at the written direction of the Government (the beneficiary) in a form satisfactory to the issuing financial institution and the confirming financial institution, if any.
5. This Letter of Credit is subject to the Uniform Customs and Practice (UCP) for Documentary extent not inconsistent therewith, to the laws of _____________________ [state of confirming financial institution, if any, otherwise state of issuing financial institution].
6. If this credit expires during an interruption of business of this financial institution as described in Article 17 of the UCP, the financial institution specifically agrees to effect payment if this credit is drawn against within 30 days after the resumption of our business.
[Issuing financial institution]
ORDER FOR SUPPLIES OR SERVICES PAGE OF PAGES
IMPORTANT: Mark all packages and papers with contract and/or order numbers.
1. DATE OF ORDER 2. CONTRACT NUMBER (If any)
3. ORDER NUMBER 4. REQUISITION/REFERENCE NUMBER
5. ISSUING OFFICE (Address correspondence to)
6. SHIP TO:
a. NAME OF CONSIGNEE
b. STREET ADDRESS
c. CITY d. STATE e. ZIP CODE
f. SHIP VIA
8. TYPE OF ORDER
a. PURCHASE
REFERENCE YOUR:
7. TO:
a. NAME OF CONTRACTOR
b. COMPANY NAME
c. STREET ADDRESS
d. CITY e. STATE f. ZIP CODE
b. DELIVERY -- Except for billing instructions on the reverse, this delivery order is subject to instructions contained on this side only of this form and is issued subject to the terms and conditions of the above-numbered contract.
17. SCHEDULE (See reverse for Rejections)
22. UNITED STATES OF
AMERICA BY (Signature)
23. NAME (Typed)
TITLE: CONTRACTING/ORDERING OFFICER
SEE BILLING
INSTRUCTIONS
ON
REVERSE
18. SHIPPING POINT 19. GROSS SHIPPING WEIGHT 20. INVOICE NUMBER
21. MAIL INVOICE TO:
a. NAME
b. STREET ADDRESS (or P.O. Box)
c. CITY d. STATE e. ZIP CODE
17(h) TOT.
(Cont.
pages)
17(i)
GRAND
TOTAL
OPTIONAL FORM 347 (REV. 2/2012)
Prescribed by GSA/FAR 48 CFR 53.213(f)
9. ACCOUNTING AND APPROPRIATION DATA 10. REQUISITIONING OFFICE
11. BUSINESS CLASSIFICATION (Check appropriate box(es))
a. SMALL
Please furnish the following on the terms and conditions specified on both sides of this order and on the attached sheet, if any, including delivery as indicated.
AUTHORIZED FOR LOCAL REPRODUCTION
PREVIOUS EDITION NOT USABLE
d. WOMEN-OWNED
h. EDWOSB
12. F.O.B. POINT
13. PLACE OF
a. INSPECTION b. ACCEPTANCE
14. GOVERNMENT B/L NUMBER 15. DELIVER TO F.O.B. POINT ON
OR BEFORE (Date)
16. DISCOUNT TERMS
b. OTHER THAN SMALL c. DISADVANTAGED
g. WOMEN-OWNED SMALL BUSINESS (WOSB)
ELIGIBLE UNDER THE WOSB PROGRAM
e. HUBZone
f. SERVICE-DISABLED
VETERAN-OWNED
ITEM
NUMBER
(a)
SUPPLIES OR SERVICES
(b)
QUANTITY
ORDERED
(c)
UNIT
(d)
UNIT
PRICE
(e)
AMOUNT
(f)
ACCEPTED
(g)
SUPPLEMENTAL INVOICING INFORMATION
If desired, this order (or a copy thereof) may be used by the Contractor as the Contractor's invoice, instead of a separate invoice, provided the following statement, (signed and dated) is on (or attached to) the order: "Payment is requested in the amount of $ . No other invoice will be submitted."
However, if the Contractor wishes to submit an invoice, the following information must be provided: contract number (if any), order number, item number(s), description of supplies or service, sizes, quantities, unit prices, and extended totals. Prepaid shipping costs will be indicated as a separate item on the invoice. Where shipping costs exceed $10 (except for parcel post), the billing must be supported by a bill of lading or receipt. When several orders are invoiced to an ordering activity during the same billing period, consolidated periodic billings are encouraged.
RECEIVING REPORT
SHIPMENT
PARTIAL
FINAL
DATE RECEIVED SIGNATURE OF AUTHORIZED U.S. GOVERNMENT REPRESENTATIVE DATE
TOTAL CONTAINERS GROSS WEIGHT RECEIVED AT TITLE
REPORT OF REJECTIONS
ITEM
NUMBER SUPPLIES OR SERVICES UNIT
REJECTED REASON FOR REJECTION
OPTIONAL FORM 347 (REV. 2/2012) BACK
Quantity in the "Quantity Accepted" column on the face of this order has been:
and conforms to contract. Items listed below have been rejected for the reasons indicated.
inspected, accepted, received by me
Order for Supplies or Services forms@gsa.gov
August 2012
August 2012
ORDER FOR SUPPLIES OR SERVICES
PAGE
OF
PAGES
IMPORTANT: Mark all packages and papers with contract and/or order numbers.
1. DATE OF ORDER
2. CONTRACT NUMBER (If any)
3. ORDER NUMBER
4. REQUISITION/REFERENCE NUMBER
5. ISSUING OFFICE (Address correspondence to)
6. SHIP TO:
a. NAME OF CONSIGNEE
b. STREET ADDRESS
c. CITY
d. STATE
e. ZIP CODE
f. SHIP VIA
8. TYPE OF ORDER
a. PURCHASE
REFERENCE YOUR:
7. TO:
a. NAME OF CONTRACTOR
b. COMPANY NAME
c. STREET ADDRESS
d. CITY
e. STATE
f. ZIP CODE
f. ZIPCODE
b. DELIVERY -- Except for billing instructions on the reverse, this delivery order is subject to instructions contained on this side only of this form and is issued subject to the terms and conditions of the above-numbered contract.
17. SCHEDULE (See reverse for Rejections)
22. UNITED STATES OF
AMERICA BY (Signature)
23. NAME (Typed)
TITLE: CONTRACTING/ORDERING OFFICER
SEE BILLING
INSTRUCTIONS
ON
REVERSE
18. SHIPPING POINT
19. GROSS SHIPPING WEIGHT
20. INVOICE NUMBER
21. MAIL INVOICE TO:
a. NAME
b. STREET ADDRESS (or P.O. Box)
c. CITY
d. STATE
e. ZIP CODE
17(h) TOT.
(Cont.
pages)
17(i)
GRAND
TOTAL
OPTIONAL FORM 347 (REV. 2/2012)
Prescribed by GSA/FAR 48 CFR 53.213(f)
9. ACCOUNTING AND APPROPRIATION DATA
10. REQUISITIONING OFFICE
11. BUSINESS CLASSIFICATION (Check appropriate box(es))
a. SMALL
Please furnish the following on the terms and conditions specified on both sides of this order and on the attached sheet, if any, including delivery as indicated.
AUTHORIZED FOR LOCAL REPRODUCTION PREVIOUS EDITION NOT USABLE
d. WOMEN-OWNED
h. EDWOSB
12. F.O.B. POINT
13. PLACE OF
a. INSPECTION
b. ACCEPTANCE
14. GOVERNMENT B/L NUMBER
15. DELIVER TO F.O.B. POINT ON
OR BEFORE (Date)
16. DISCOUNT TERMS
b. OTHER THAN SMALL
c. DISADVANTAGED
g. WOMEN-OWNED SMALL BUSINESS (WOSB)
ELIGIBLE UNDER THE WOSB PROGRAM
e. HUBZone
f. SERVICE-DISABLED
VETERAN-OWNED
ITEM
NUMBER
(a)
SUPPLIES OR SERVICES
(b)
QUANTITY
ORDERED
(c)
UNIT
(d)
UNIT
PRICE
(e)
AMOUNT
(f)
QUANTITY
ACCEPTED
(g)
SUPPLEMENTAL INVOICING INFORMATION
If desired, this order (or a copy thereof) may be used by the Contractor as the Contractor's invoice, instead of a separate invoice, provided the following statement, (signed and dated) is on (or attached to) the order: "Payment is requested in the amount of $ . No other invoice will be submitted." However, if the Contractor wishes to submit an invoice, the following information must be provided: contract number (if any), order number, item number(s), description of supplies or service, sizes, quantities, unit prices, and extended totals. Prepaid shipping costs will be indicated as a separate item on the invoice. Where shipping costs exceed $10 (except for parcel post), the billing must be supported by a bill of lading or receipt. When several orders are invoiced to an ordering activity during the same billing period, consolidated periodic billings are encouraged.
RECEIVING REPORT
SHIPMENT
NUMBER
PARTIAL
FINAL
DATE RECEIVED
SIGNATURE OF AUTHORIZED U.S. GOVERNMENT REPRESENTATIVE
DATE
TOTAL CONTAINERS
GROSS WEIGHT
RECEIVED AT
TITLE
REPORT OF REJECTIONS
ITEM
NUMBER
SUPPLIES OR SERVICES
UNIT
QUANTITY
REJECTED
REASON FOR REJECTION
OPTIONAL FORM 347 (REV. 2/2012) BACK
Quantity in the "Quantity Accepted" column on the face of this order has been:
and conforms to contract. Items listed below have been rejected for the reasons indicated.
inspected, accepted, received by me
11d. BUSINESS CLASSIFICATION (Check appropriate box(es)). WOMEN-OWNED.: 0
11d. BUSINESS CLASSIFICATION (Check appropriate box(es)). WOMEN-OWNED.: 0
11c. BUSINESS CLASSIFICATION (Check appropriate box(es)). DISADVANTAGED.: 0
11c. BUSINESS CLASSIFICATION (Check appropriate box(es)). DISADVANTAGED.: 0
PAGE. (Enter page number).:
OF PAGES. (Enter total pages).:
1. DATE OF ORDER. Enter 2 digit month, 2 digit day and 4 digit year.:
2. CONTRACT NUMBER (If any). :
3. ORDER NUMBER.:
4. REQUISITION/REFERENCE NUMBER.:
5. ISSUING OFFICE (Address correspondence to) :
a. NAME OF CONTRACTOR.:
b. COMPANY NAME.:
c. STREET ADDRESS.:
c. CITY.:
e. STATE.:
21e. MAIL INVOICE TO: ZIP CODE.:
9. ACCOUNTING AND APPROPRIATION DATA.:
a. NAME OF CONSIGNEE.:
b. STREET ADDRESS.:
d. STATE.:
e. ZIP CODE.:
f. SHIP VIA.:
8a. TYPE OF ORDER. PURCHASE.: 0
8b. TYPE OF ORDER. DELIVERY -- Except for billing instructions on the reverse, this delivery order is subject to instructions contained on this side only of this form and is issued subject to the terms and conditions of the above-numbered contract.: 0
REFERENCE YOUR. Please furnish the following on the terms and conditions specified on both sides of this order and on the attached sheet, if any, including delivery as indicated.:
10. REQUISITIONING OFFICE.:
11a. BUSINESS CLASSIFICATION (Check appropriate box(es)). SMALL.: 0
11e. BUSINESS CLASSIFICATION (Check appropriate box(es)). HUB Zone: 0
11b. BUSINESS CLASSIFICATION (Check appropriate box(es)). OTHER THAN SMALL.: 0
11f. BUSINESS CLASSIFICATION (Check appropriate box(es)). SERVICE-DISABLED VETERAN-OWNED.: 0
12. F. O. B. POINT.:
13a. PLACE OF INSPECTION.:
13b. PLACE OF ACCEPTANCE.:
14. GOVERNMENT B/L NUMBER.:
15. DELIVER TO F.O.B. POINT ON OR BEFORE (date) Enter 2 digit month, 2 digit day and 4 digit year.:
16. DISCOUNT TERMS.:
17b. SCHEDULE (See reverse for Rejections). SUPPLIES OR SERVICES.:
17a. SCHEDULE (See reverse for Rejections). ITEM NUMBER. Line 1 of 13.:
17c. SCHEDULE (See reverse for Rejections). QUANTITY ORDERED.:
17d. SCHEDULE (See reverse for Rejections). UNIT.:
17f. SCHEDULE (See reverse for Rejections). AMOUNT.: 0.00000000
17g. SCHEDULE (See reverse for Rejections). QUANTITY ACCEPTED.:
17a. SCHEDULE (See reverse for Rejections). ITEM NUMBER. Line 11 of 13.:
17g. SCHEDULE (See reverse for Rejections). QUANTITY ACCEPTED.:
17f. SCHEDULE (See reverse for Rejections). AMOUNT.: 0.00000000
17e. SCHEDULE (See reverse for Rejections). UNIT PRICE.:
17d. SCHEDULE (See reverse for Rejections). UNIT.:
17c. SCHEDULE (See reverse for Rejections). QUANTITY ORDERED.:
17b. SCHEDULE (See reverse for Rejections). SUPPLIES OR SERVICES.:
17a. SCHEDULE (See reverse for Rejections). ITEM NUMBER. Line 13 of 13.:
17g. SCHEDULE (See reverse for Rejections). QUANTITY ACCEPTED.:
17f. SCHEDULE (See reverse for Rejections). AMOUNT.: 0.00000000
17e. SCHEDULE (See reverse for Rejections). UNIT PRICE.:
17d. SCHEDULE (See reverse for Rejections). UNIT.:
17c. SCHEDULE (See reverse for Rejections). QUANTITY ORDERED.:
17b. SCHEDULE (See reverse for Rejections). SUPPLIES OR SERVICES.:
17a. SCHEDULE (See reverse for Rejections). ITEM NUMBER. Line 12 of 13.:
17b. SCHEDULE (See reverse for Rejections). SUPPLIES OR SERVICES.:
17c. SCHEDULE (See reverse for Rejections). QUANTITY ORDERED.:
17d. SCHEDULE (See reverse for Rejections). UNIT.:
17e. SCHEDULE (See reverse for Rejections). UNIT PRICE.:
17f. SCHEDULE (See reverse for Rejections). AMOUNT.: 0.00000000
17g. SCHEDULE (See reverse for Rejections). QUANTITY ACCEPTED.:
17a. SCHEDULE (See reverse for Rejections). ITEM NUMBER. Line 10 of 13.:
17b. SCHEDULE (See reverse for Rejections). SUPPLIES OR SERVICES.:
17c. SCHEDULE (See reverse for Rejections). QUANTITY ORDERED.:
17d. SCHEDULE (See reverse for Rejections). UNIT.:
17e. SCHEDULE (See reverse for Rejections). UNIT PRICE.:
17f. SCHEDULE (See reverse for Rejections). AMOUNT.: 0.00000000
17g. SCHEDULE (See reverse for Rejections). QUANTITY ACCEPTED.:
17a. SCHEDULE (See reverse for Rejections). ITEM NUMBER. Line 9 of 13.:
17b. SCHEDULE (See reverse for Rejections). SUPPLIES OR SERVICES.:
17c. SCHEDULE (See reverse for Rejections). QUANTITY ORDERED.:
17d. SCHEDULE (See reverse for Rejections). UNIT.:
17e. SCHEDULE (See reverse for Rejections). UNIT PRICE.:
17f. SCHEDULE (See reverse for Rejections). AMOUNT.: 0.00000000
17g. SCHEDULE (See reverse for Rejections). QUANTITY ACCEPTED.:
17a. SCHEDULE (See reverse for Rejections). ITEM NUMBER. Line 8 of 13.:
17b. SCHEDULE (See reverse for Rejections). SUPPLIES OR SERVICES.:
17c. SCHEDULE (See reverse for Rejections). QUANTITY ORDERED.:
17d. SCHEDULE (See reverse for Rejections). UNIT.:
17e. SCHEDULE (See reverse for Rejections). UNIT PRICE.:
17f. SCHEDULE (See reverse for Rejections). AMOUNT.: 0.00000000
17g. SCHEDULE (See reverse for Rejections). QUANTITY ACCEPTED.:
17a. SCHEDULE (See reverse for Rejections). ITEM NUMBER. Line 7 of 13.:
17b. SCHEDULE (See reverse for Rejections). SUPPLIES OR SERVICES.:
17c. SCHEDULE (See reverse for Rejections). QUANTITY ORDERED.:
17d. SCHEDULE (See reverse for Rejections). UNIT.:
17e. SCHEDULE (See reverse for Rejections). UNIT PRICE.:
17f. SCHEDULE (See reverse for Rejections). AMOUNT.: 0.00000000
17g. SCHEDULE (See reverse for Rejections). QUANTITY ACCEPTED.:
17a. SCHEDULE (See reverse for Rejections). ITEM NUMBER. Line 6 of 13.:
17b. SCHEDULE (See reverse for Rejections). SUPPLIES OR SERVICES.:
17c. SCHEDULE (See reverse for Rejections). QUANTITY ORDERED.:
17d. SCHEDULE (See reverse for Rejections). UNIT.:
17e. SCHEDULE (See reverse for Rejections). UNIT PRICE.:
17f. SCHEDULE (See reverse for Rejections). AMOUNT.: 0.00000000
17g. SCHEDULE (See reverse for Rejections). QUANTITY ACCEPTED.:
17a. SCHEDULE (See reverse for Rejections). ITEM NUMBER. Line 5 of 13.:
17b. SCHEDULE (See reverse for Rejections). SUPPLIES OR SERVICES.:
17c. SCHEDULE (See reverse for Rejections). QUANTITY ORDERED.:
17d. SCHEDULE (See reverse for Rejections). UNIT.:
17e. SCHEDULE (See reverse for Rejections). UNIT PRICE.:
17f. SCHEDULE (See reverse for Rejections). AMOUNT.: 0.00000000
17g. SCHEDULE (See reverse for Rejections). QUANTITY ACCEPTED.:
17a. SCHEDULE (See reverse for Rejections). ITEM NUMBER. Line 4 of 13.:
17b. SCHEDULE (See reverse for Rejections). SUPPLIES OR SERVICES.:
17c. SCHEDULE (See reverse for Rejections). QUANTITY ORDERED.:
17d. SCHEDULE (See reverse for Rejections). UNIT.:
17e. SCHEDULE (See reverse for Rejections). UNIT PRICE.:
17f. SCHEDULE (See reverse for Rejections). AMOUNT.: 0.00000000
17g. SCHEDULE (See reverse for Rejections). QUANTITY ACCEPTED.:
17a. SCHEDULE (See reverse for Rejections). ITEM NUMBER. Line 3 of 13.:
17b. SCHEDULE (See reverse for Rejections). SUPPLIES OR SERVICES.:
17c. SCHEDULE (See reverse for Rejections). QUANTITY ORDERED.:
17d. SCHEDULE (See reverse for Rejections). UNIT.:
17e. SCHEDULE (See reverse for Rejections). UNIT PRICE.:
17f. SCHEDULE (See reverse for Rejections). AMOUNT.: 0.00000000
17g. SCHEDULE (See reverse for Rejections). QUANTITY ACCEPTED.:
17a. SCHEDULE (See reverse for Rejections). ITEM NUMBER. Line 2 of 13.:
17b. SCHEDULE (See reverse for Rejections). SUPPLIES OR SERVICES.:
17c. SCHEDULE (See reverse for Rejections). QUANTITY ORDERED.:
17d. SCHEDULE (See reverse for Rejections). UNIT.:
17e. SCHEDULE (See reverse for Rejections). UNIT PRICE.:
17f. SCHEDULE (See reverse for Rejections). AMOUNT.: 0.00000000
17g. SCHEDULE (See reverse for Rejections). QUANTITY ACCEPTED.:
17e. SCHEDULE (See reverse for Rejections). UNIT PRICE.:
18. SHIPPING POINT.:
20. INVOICE NUMBER.:
21a. MAIL INVOICE TO: NAME.:
21b. MAIL INVOICE TO: STREET ADDRESS (or P.O. Box).:
21c. MAIL INVOICE TO: CITY.:
21d. MAIL INVOICE TO: STATE.:
17(h) TOTAL (CONTINUED PAGES).:
17(i) GRAND TOTAL. :
23. NAME (Typed).:
19. GROSS SHIPPING WEIGHT.:
SIGNATURE OF AUTHORIZED U.S. GOVERNMENT REPRESENTATIVE (Digital Signature):
Payment is requested in the amount of $ (amount).:
RECEIVING REPORT. Quantity in the "Quantity Accepted" column on the face of this order has been: Inspected.: 0
RECEIVING REPORT. Quantity in the "Quantity Accepted" column on the face of this order has been: Accepted.: 0
RECEIVING REPORT. Quantity in the "Quantity Accepted" column on the face of this order has been: Received by me.: 0
SHIPMENT NUMBER. PARTIAL.:
SHIPMENT NUMBER. FINAL.:
DATE RECEIVED. Enter 2 digit month, 2 digit day and 4 digit year.:
TOTAL CONTAINERS.:
RECEIVED AT.:
DATE. Enter 2 digit month, 2 digit day and 4 digit year.:
TITLE.:
REPORT OF REJECTIONS. ITEM NUMBER. Line 1 of 36.:
REPORT OF REJECTION. REASON FOR REJECTION.:
REPORT OF REJECTIONS. QUANTITY
REJECTED.:
REPORT OF REJECTIONS. UNIT.:
REPORT OF REJECTIONS. SUPPLIES OR SERVICES.:
REPORT OF REJECTIONS. ITEM NUMBER. Line 21 of 36.:
REPORT OF REJECTION. REASON FOR REJECTION.:
REPORT OF REJECTIONS. QUANTITY
REJECTED.:
REPORT OF REJECTIONS. UNIT.:
REPORT OF REJECTIONS. SUPPLIES OR SERVICES.:
REPORT OF REJECTIONS. ITEM NUMBER. Line 36 of 36.:
REPORT OF REJECTION. REASON FOR REJECTION.:
REPORT OF REJECTIONS. QUANTITY
REJECTED.:
REPORT OF REJECTIONS. UNIT.:
REPORT OF REJECTIONS. SUPPLIES OR SERVICES.:
REPORT OF REJECTIONS. ITEM NUMBER. Line 35 of 36.:
REPORT OF REJECTION. REASON FOR REJECTION.:
REPORT OF REJECTIONS. QUANTITY
REJECTED.:
REPORT OF REJECTIONS. UNIT.:
REPORT OF REJECTIONS. SUPPLIES OR SERVICES.:
REPORT OF REJECTIONS. ITEM NUMBER. Line 34 of 36.:
REPORT OF REJECTION. REASON FOR REJECTION.:
REPORT OF REJECTIONS. QUANTITY
REJECTED.:
REPORT OF REJECTIONS. UNIT.:
REPORT OF REJECTIONS. SUPPLIES OR SERVICES.:
REPORT OF REJECTIONS. ITEM NUMBER. Line 33 of 36.:
REPORT OF REJECTION. REASON FOR REJECTION.:
REPORT OF REJECTIONS. QUANTITY
REJECTED.:
REPORT OF REJECTIONS. UNIT.:
REPORT OF REJECTIONS. SUPPLIES OR SERVICES.:
REPORT OF REJECTIONS. ITEM NUMBER. Line 32 of 36.:
REPORT OF REJECTION. REASON FOR REJECTION.:
REPORT OF REJECTIONS. QUANTITY
REJECTED.:
REPORT OF REJECTIONS. UNIT.:
REPORT OF REJECTIONS. SUPPLIES OR SERVICES.:
REPORT OF REJECTIONS. ITEM NUMBER. Line 31 of 36.:
REPORT OF REJECTION. REASON FOR REJECTION.:
REPORT OF REJECTIONS. QUANTITY
REJECTED.:
REPORT OF REJECTIONS. UNIT.:
REPORT OF REJECTIONS. SUPPLIES OR SERVICES.:
REPORT OF REJECTIONS. ITEM NUMBER. Line 30 of 36.:
REPORT OF REJECTION. REASON FOR REJECTION.:
REPORT OF REJECTIONS. QUANTITY
REJECTED.:
REPORT OF REJECTIONS. UNIT.:
REPORT OF REJECTIONS. SUPPLIES OR SERVICES.:
REPORT OF REJECTIONS. ITEM NUMBER. Line 29 of 36.:
REPORT OF REJECTION. REASON FOR REJECTION.:
REPORT OF REJECTIONS. QUANTITY
REJECTED.:
REPORT OF REJECTIONS. UNIT.:
REPORT OF REJECTIONS. SUPPLIES OR SERVICES.:
REPORT OF REJECTIONS. ITEM NUMBER. Line 28 of 36.:
REPORT OF REJECTION. REASON FOR REJECTION.:
REPORT OF REJECTIONS. QUANTITY
REJECTED.:
REPORT OF REJECTIONS. UNIT.:
REPORT OF REJECTIONS. SUPPLIES OR SERVICES.:
REPORT OF REJECTIONS. ITEM NUMBER. Line 27 of 36.:
REPORT OF REJECTION. REASON FOR REJECTION.:
REPORT OF REJECTIONS. QUANTITY
REJECTED.:
REPORT OF REJECTIONS. UNIT.:
REPORT OF REJECTIONS. SUPPLIES OR SERVICES.:
REPORT OF REJECTIONS. ITEM NUMBER. Line 26 of 36.:
REPORT OF REJECTION. REASON FOR REJECTION.:
REPORT OF REJECTIONS. QUANTITY
REJECTED.:
REPORT OF REJECTIONS. UNIT.:
REPORT OF REJECTIONS. SUPPLIES OR SERVICES.:
REPORT OF REJECTIONS. ITEM NUMBER. Line 25 of 36.:
REPORT OF REJECTION. REASON FOR REJECTION.:
REPORT OF REJECTIONS. QUANTITY
REJECTED.:
REPORT OF REJECTIONS. UNIT.:
REPORT OF REJECTIONS. SUPPLIES OR SERVICES.:
REPORT OF REJECTIONS. ITEM NUMBER. Line 24 of 36.:
REPORT OF REJECTION. REASON FOR REJECTION.:
REPORT OF REJECTIONS. QUANTITY
REJECTED.:
REPORT OF REJECTIONS. UNIT.:
REPORT OF REJECTIONS. SUPPLIES OR SERVICES.:
REPORT OF REJECTIONS. ITEM NUMBER. Line 23 of 36.:
REPORT OF REJECTION. REASON FOR REJECTION.:
REPORT OF REJECTIONS. QUANTITY
REJECTED.:
REPORT OF REJECTIONS. UNIT.:
REPORT OF REJECTIONS. SUPPLIES OR SERVICES.:
REPORT OF REJECTIONS. ITEM NUMBER. Line 22 of 36. :
REPORT OF REJECTION. REASON FOR REJECTION.:
REPORT OF REJECTIONS. QUANTITY
REJECTED.:
REPORT OF REJECTIONS. UNIT.:
REPORT OF REJECTIONS. SUPPLIES OR SERVICES.:
REPORT OF REJECTIONS. ITEM NUMBER. Line 20 of 36.:
REPORT OF REJECTION. REASON FOR REJECTION.:
REPORT OF REJECTIONS. QUANTITY
REJECTED.:
REPORT OF REJECTIONS. UNIT.:
REPORT OF REJECTIONS. SUPPLIES OR SERVICES.:
REPORT OF REJECTIONS. ITEM NUMBER. Line 19 of 36.:
REPORT OF REJECTION. REASON FOR REJECTION.:
REPORT OF REJECTIONS. QUANTITY
REJECTED.:
REPORT OF REJECTIONS. UNIT.:
REPORT OF REJECTIONS. SUPPLIES OR SERVICES.:
REPORT OF REJECTIONS. ITEM NUMBER. Line 18 of 36.:
REPORT OF REJECTION. REASON FOR REJECTION.:
REPORT OF REJECTIONS. QUANTITY
REJECTED.:
REPORT OF REJECTIONS. UNIT.:
REPORT OF REJECTIONS. SUPPLIES OR SERVICES.:
REPORT OF REJECTIONS. ITEM NUMBER. Line 17 of 36.:
REPORT OF REJECTION. REASON FOR REJECTION.:
REPORT OF REJECTIONS. QUANTITY
REJECTED.:
REPORT OF REJECTIONS. UNIT.:
REPORT OF REJECTIONS. SUPPLIES OR SERVICES.:
REPORT OF REJECTIONS. ITEM NUMBER. Line 16 of 36.:
REPORT OF REJECTION. REASON FOR REJECTION.:
REPORT OF REJECTIONS. QUANTITY
REJECTED.:
REPORT OF REJECTIONS. UNIT.:
REPORT OF REJECTIONS. SUPPLIES OR SERVICES.:
REPORT OF REJECTIONS. ITEM NUMBER. Line 14 of 36.:
REPORT OF REJECTION. REASON FOR REJECTION.:
REPORT OF REJECTIONS. QUANTITY
REJECTED.:
REPORT OF REJECTIONS. UNIT.:
REPORT OF REJECTIONS. SUPPLIES OR SERVICES.:
REPORT OF REJECTIONS. ITEM NUMBER. Line 13 of 36.:
REPORT OF REJECTION. REASON FOR REJECTION.:
REPORT OF REJECTIONS. QUANTITY
REJECTED.:
REPORT OF REJECTIONS. UNIT.:
REPORT OF REJECTIONS. SUPPLIES OR SERVICES.:
REPORT OF REJECTIONS. ITEM NUMBER. Line 12 of 36.:
REPORT OF REJECTION. REASON FOR REJECTION.:
REPORT OF REJECTIONS. QUANTITY
REJECTED.:
REPORT OF REJECTIONS. UNIT.:
REPORT OF REJECTIONS. SUPPLIES OR SERVICES.:
REPORT OF REJECTIONS. ITEM NUMBER. Line 11 of 36.:
REPORT OF REJECTION. REASON FOR REJECTION.:
REPORT OF REJECTIONS. QUANTITY
REJECTED.:
REPORT OF REJECTIONS. UNIT.:
REPORT OF REJECTIONS. SUPPLIES OR SERVICES.:
REPORT OF REJECTIONS. ITEM NUMBER. Line 10 of 36.:
REPORT OF REJECTION. REASON FOR REJECTION.:
REPORT OF REJECTIONS. QUANTITY
REJECTED.:
REPORT OF REJECTIONS. UNIT.:
REPORT OF REJECTIONS. SUPPLIES OR SERVICES.:
REPORT OF REJECTIONS. ITEM NUMBER. Line 9 of 36.:
REPORT OF REJECTION. REASON FOR REJECTION.:
REPORT OF REJECTIONS. QUANTITY
REJECTED.:
REPORT OF REJECTIONS. UNIT.:
REPORT OF REJECTIONS. SUPPLIES OR SERVICES.:
REPORT OF REJECTIONS. ITEM NUMBER. Line 8 of 36.:
REPORT OF REJECTION. REASON FOR REJECTION.:
REPORT OF REJECTIONS. QUANTITY
REJECTED.:
REPORT OF REJECTIONS. UNIT.:
REPORT OF REJECTIONS. SUPPLIES OR SERVICES.:
REPORT OF REJECTIONS. ITEM NUMBER. Line 7 of 36.:
REPORT OF REJECTION. REASON FOR REJECTION.:
REPORT OF REJECTIONS. QUANTITY
REJECTED.:
REPORT OF REJECTIONS. UNIT.:
REPORT OF REJECTIONS. SUPPLIES OR SERVICES.:
REPORT OF REJECTIONS. ITEM NUMBER. Line 6 of 36.:
REPORT OF REJECTION. REASON FOR REJECTION.:
REPORT OF REJECTIONS. QUANTITY
REJECTED.:
REPORT OF REJECTIONS. UNIT.:
REPORT OF REJECTIONS. SUPPLIES OR SERVICES.:
REPORT OF REJECTIONS. ITEM NUMBER. Line 5 of 36.:
REPORT OF REJECTION. REASON FOR REJECTION.:
REPORT OF REJECTIONS. QUANTITY
REJECTED.:
REPORT OF REJECTIONS. UNIT.:
REPORT OF REJECTIONS. SUPPLIES OR SERVICES.:
REPORT OF REJECTIONS. ITEM NUMBER. Line 4 of 36.:
REPORT OF REJECTION. REASON FOR REJECTION.:
REPORT OF REJECTIONS. QUANTITY
REJECTED.:
REPORT OF REJECTIONS. UNIT.:
REPORT OF REJECTIONS. SUPPLIES OR SERVICES.:
REPORT OF REJECTIONS. ITEM NUMBER. Line 3 of 36.:
REPORT OF REJECTION. REASON FOR REJECTION.:
REPORT OF REJECTIONS. QUANTITY
REJECTED.:
REPORT OF REJECTIONS. UNIT.:
REPORT OF REJECTIONS. SUPPLIES OR SERVICES.:
REPORT OF REJECTIONS. ITEM NUMBER. Line 2 of 36.:
REPORT OF REJECTIONS. SUPPLIES OR SERVICES.:
REPORT OF REJECTIONS. UNIT.:
REPORT OF REJECTIONS. QUANTITY
REJECTED.:
REPORT OF REJECTION. REASON FOR REJECTION.:
GROSS WEIGHT.:
STATEMENT AND ACKNOWLEDGMENT OMB Control Number: 9000-0014 Expiration Date: 12/31/2017
PART I - STATEMENT OF PRIME CONTRACTOR
1. PRIME CONTRACT NO. 2. DATE SUBCONTRACT
AWARDED
3. SUBCONTRACT NUMBER
15b. TITLE OF PERSON SIGNING
PREVIOUS EDITION IS NOT USABLE
STANDARD FORM 1413 (REV. 4/2013)
Prescribed by GSA/FAR (48 CFR) 53.222(e)
4. PRIME CONTRACTOR 5. SUBCONTRACTOR
a. NAME a. NAME
b. STREET ADDRESS b. STREET ADDRESS
c. CITY d. STATE e. ZIP CODE c. CITY d. STATE e. ZIP CODE
6. The prime contract does, does not contain the clause entitled "Contract Work Hours and Safety Standards Act -- Overtime Compensation."
7. The prime contractor states that under the contract shown in Item 1, a subcontract was awarded on the date shown in Item 2 to the subcontractor identified in item 5 by the following firm:
a. NAME OF AWARDING FIRM
b. DESCRIPTION OF WORK BY SUBCONTRACTOR
8. PROJECT 9. LOCATION
10a. NAME OF PERSON SIGNING 11. BY (Signature) 12. DATE SIGNED
10b. TITLE OF PERSON SIGNING
PART II - ACKNOWLEDGMENT OF SUBCONTRACTOR
13. 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 (If included in prime contract see Block 6) Payrolls and Basic Records Withholding of Funds Disputes Concerning Labor Standards Compliance with Construction Wage Rate Requirements and Related Regulations
Construction Wage Rate Requirements Apprentices and Trainees Compliance with Copeland Act Requirements Subcontracts (Labor Standards) Contract Termination - Debarment Certification of Eligibility
14. NAME(S) OF ANY INTERMEDIATE SUBCONTRACTORS, IF ANY
A C
B D
15a. NAME OF PERSON SIGNING 16. BY (Signature) 17. DATE SIGNED
PAPERWORK REDUCTION ACT STATEMENT: Public reporting burden for this collection of information is estimated to average .05 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspects of this collection of information, including suggestions for reducing this burden, to U.S. General Services Administration, Regulatory Secretariat (MVCB)/IC 9000-0014, Office of Governmentwide Acquisition Policy,1800 F Street, NW, Washington, DC 20405.
1.6
Presentation Agent
PDFlib 3.02 (C++/Win32)
D:20050617125503-04'00'
D:20080212101247-05'00'
STATEMENT AND ACKNOWLEDGMENT
OMB Control Number: 9000-0014
Expiration Date: 12/31/2017
PART I - STATEMENT OF PRIME CONTRACTOR
1. PRIME CONTRACT NO.
2. DATE SUBCONTRACT AWARDED
3. SUBCONTRACT NUMBER
15b. TITLE OF PERSON SIGNING
AUTHORIZED FOR LOCAL REPRODUCTION PREVIOUS EDITION IS NOT USABLE
STANDARD FORM 1413 (REV. 4/2013)
Prescribed by GSA/FAR (48 CFR) 53.222(e)
4. PRIME CONTRACTOR
5. SUBCONTRACTOR
a. NAME
a. NAME
b. STREET ADDRESS
b. STREET ADDRESS
c. CITY
d. STATE
e. ZIP CODE
c. CITY
d. STATE
e. ZIP CODE
6. The prime contract does, does not contain the clause entitled "Contract Work Hours and Safety Standards Act -- Overtime Compensation."
7. The prime contractor states that under the contract shown in Item 1, a subcontract was awarded on the date shown in Item 2 to the subcontractor identified in item 5 by the following firm:
a. NAME OF AWARDING FIRM
b. DESCRIPTION OF WORK BY SUBCONTRACTOR
8. PROJECT
9. LOCATION
10a. NAME OF PERSON SIGNING
11. BY (Signature)
12. DATE SIGNED
10b. TITLE OF PERSON SIGNING
PART II - ACKNOWLEDGMENT OF SUBCONTRACTOR
13. 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
(If included in prime contract see Block 6)
Payrolls and Basic RecordsWithholding of FundsDisputes Concerning Labor StandardsCompliance with Construction Wage Rate Requirements and Related Regulations
Construction Wage Rate Requirements Apprentices and Trainees Compliance with Copeland Act Requirements Subcontracts (Labor Standards) Contract Termination - Debarment Certification of Eligibility
14. NAME(S) OF ANY INTERMEDIATE SUBCONTRACTORS, IF ANY
A
C
B
D
15a. NAME OF PERSON SIGNING
16. BY (Signature)
17. DATE SIGNED
PAPERWORK REDUCTION ACT STATEMENT: Public reporting burden for this collection of information is estimated to average .05 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspects of this collection of information, including suggestions for reducing this burden, to U.S. General Services Administration, Regulatory Secretariat (MVCB)/IC 9000-0014, Office of Governmentwide Acquisition Policy,1800 F Street, NW, Washington, DC 20405.
1. PRIME CONTRACT NUMBER:
4A. NAME:
4B. STREET ADDRESS:
4C. CITY:
7A. NAME OF AWARDING FIRM:
10A. NAME OF PERSON SIGNING:
15A. NAME OF PERSON SIGNING:
15B. TITLE OF PERSON SIGNING:
10B. TITLE OF PERSON SIGNING:
14. NAME(S) OF ANY INTERMEDIATE SUBCONTRACTORS, IF ANY. Line A.:
14. NAME(S) OF ANY INTERMEDIATE SUBCONTRACTORS, IF ANY. Line D.:
14. NAME(S) OF ANY INTERMEDIATE SUBCONTRACTORS, IF ANY. Line C.:
14. NAME(S) OF ANY INTERMEDIATE SUBCONTRACTORS, IF ANY. Line B.:
8. PROJECT:
9. LOCATION:
7B. DESCRIPTION OF WORK BY SUBCONTRACTOR:
5C. CITY:
4E. ZIP CODE:
5E. ZIP CODE:
4D. STATE:
5D. STATE:
3. SUBCONTRACT NUMBER:
5A. NAME:
5B. STREET ADDRESS:
2. DATE SUBCONTRACT AWARDED. Enter 2 digit month, 2 digit day and 4 digit year.:
12. DATE SIGNED. Enter 2 digit month, 2 digit day and 4 digit year.:
17. DATE SIGNED. Enter 2 digit month, 2 digit day and 4 digit year.:
6. The prime contract does contain the clause entitled "Contract Work Hours and Safety Standards Act -- Overtime Compensation.": 0
6. The prime contract does not contain the clause entitled "Contract Work Hours and Safety Standards Act -- Overtime Compensation.": 0
11. BY. SIGNATURE. This is a protected field.:
16. BY. SIGNATURE. This is a protected field.:
REQUEST FOR AUTHORIZATION OF
ADDITIONAL CLASSIFICATION AND RATE
INSTRUCTIONS: THE CONTRACTOR SHALL COMPLETE ITEMS 3 THROUGH 16, KEEP A PENDING COPY, AND SUBMIT THE REQUEST, IN
QUADRUPLICATE, TO THE CONTRACTING OFFICER.
1. TO:
ADMINISTRATOR,
WAGE AND HOUR DIVISION
U.S. DEPARTMENT OF LABOR
WASHINGTON, DC 20210
2. FROM: (REPORTING OFFICE)
3. CONTRACTOR 4. DATE OF REQUEST
5. CONTRACT NUMBER 6. DATE BID OPENED (SEALED
BIDDING)
7. DATE OF AWARD 8. DATE CONTRACT WORK
STARTED
9. DATE OPTION EXERCISED (If
APPLICABLE) (SERVICE
CONTRACT ONLY)
10. SUBCONTRACTOR (IF ANY)
11. PROJECT AND DESCRIPTION OF WORK (ATTACH ADDITIONAL SHEET IF NEEDED)
12. LOCATION (CITY, COUNTY AND STATE)
13. IN ORDER TO COMPLETE THE WORK PROVIDED FOR UNDER THE ABOVE CONTRACT, IT IS NECESSARY TO ESTABLISH THE FOLLOWING RATE(S) FOR THE INDICATED CLASSIFICATION(S) NOT INCLUDED IN THE DEPARTMENT OF LABOR DETERMINATION
NUMBER: DATED:
a. LIST IN ORDER: PROPOSED CLASSIFICATION TITLE(S); JOB DESCRIPTION(S); DUTIES;
AND RATIONALE FOR PROPOSED CLASSIFICATIONS (Service contracts only) b. WAGE RATE(S)
c. FRINGE BENEFITS
PAYMENTS
(Use reverse or attach additional sheets, if necessary)
14. SIGNATURE AND TITLE OF SUBCONTRACTOR REPRESENTATIVE
(IF ANY)
15. SIGNATURE AND TITLE OF PRIME CONTRACTOR REPRESENTATIVE
16. SIGNATURE OF EMPLOYEE OR REPRESENTATIVE TITLE CHECK APPROPRIATE BOX-REFERENCING BLOCK 13.
AGREE DISAGREE
TO BE COMPLETED BY CONTRACTING OFFICER (CHECK AS APPROPRIATE - SEE FAR 22.1019 (SERVICE CONTRACT LABOR
STANDARDS) OR FAR 22.406-3 (CONSTRUCTION WAGE RATE REQUIREMENTS))
THE INTERESTED PARTIES AGREE AND THE CONTRACTING OFFICER RECOMMENDS APPROVAL BY THE WAGE AND HOUR DIVISION. AVAILABLE
INFORMATION AND RECOMMENDATIONS ARE ATTACHED.
THE INTERESTED PARTIES CANNOT AGREE ON THE PROPOSED CLASSIFICATION AND WAGE RATE. A DETERMINATION OF THE QUESTION BY THE WAGE AND HOUR DIVISION IS THEREFORE REQUESTED. AVAILABLE INFORMATION AND RECOMMENDATIONS ARE ATTACHED.
(Send 3 copies to the Department of Labor)
SIGNATURE OF CONTRACTING OFFICER OR
REPRESENTATIVE
STANDARD FORM 1444 (REV. 4/2013)
Prescribed by GSA-FAR (48 CFR) 53.222(f)
TITLE AND COMMERCIAL TELEPHONE NUMBER DATE SUBMITTED
CHECK APPROPRIATE BOX
SERVICE CONTRACT
CONSTRUCTION CONTRACT
PREVIOUS EDITION IS USABLE
PAPERWORK REDUCTION ACT STATEMENT: Public reporting burden for this collection of information is estimated to average .5 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspects of this collection of information, including suggestions for reducing this burden, to U.S. General Services Administration, Regulatory Secretariat (MVCB)/IC 9000-0089, Office of Governmentwide Acquisition Policy, 1800 F Street, NW, Washington, DC 20405.
OMB Number: 9000-0089 Expiration Date: 9/30/2017
REQUEST FOR AUTHORIZATION OF
ADDITIONAL CLASSIFICATION AND RATE
INSTRUCTIONS: THE CONTRACTOR SHALL COMPLETE ITEMS 3 THROUGH 16, KEEP A PENDING COPY, AND SUBMIT THE REQUEST, IN
QUADRUPLICATE, TO THE CONTRACTING OFFICER.
1. TO:
ADMINISTRATOR,
WAGE AND HOUR DIVISION
U.S. DEPARTMENT OF LABOR
WASHINGTON, DC 20210
2. FROM: (REPORTING OFFICE)
3. CONTRACTOR
4. DATE OF REQUEST
5. CONTRACT NUMBER
6. DATE BID OPENED (SEALED
BIDDING)
7. DATE OF AWARD
8. DATE CONTRACT WORK
STARTED
9. DATE OPTION EXERCISED (If
APPLICABLE) (SERVICE CONTRACT ONLY)
10. SUBCONTRACTOR (IF ANY)
11. PROJECT AND DESCRIPTION OF WORK (ATTACH ADDITIONAL SHEET IF NEEDED)
12. LOCATION (CITY, COUNTY AND STATE)
13. IN ORDER TO COMPLETE THE WORK PROVIDED FOR UNDER THE ABOVE CONTRACT, IT IS NECESSARY TO ESTABLISH THE FOLLOWING RATE(S) FOR THE
INDICATED CLASSIFICATION(S) NOT INCLUDED IN THE DEPARTMENT OF LABOR DETERMINATION
NUMBER:
DATED:
a. LIST IN ORDER: PROPOSED CLASSIFICATION TITLE(S); JOB DESCRIPTION(S); DUTIES;
AND RATIONALE FOR PROPOSED CLASSIFICATIONS (Service contracts only)
b. WAGE RATE(S)
c. FRINGE BENEFITS
PAYMENTS
(Use reverse or attach additional sheets, if necessary)
14. SIGNATURE AND TITLE OF SUBCONTRACTOR REPRESENTATIVE
(IF ANY)
15. SIGNATURE AND TITLE OF PRIME CONTRACTOR REPRESENTATIVE
16. SIGNATURE OF EMPLOYEE OR REPRESENTATIVE
TITLE
CHECK APPROPRIATE BOX-REFERENCING BLOCK 13.
AGREE
DISAGREE
TO BE COMPLETED BY CONTRACTING OFFICER (CHECK AS APPROPRIATE - SEE FAR 22.1019 (SERVICE CONTRACT LABOR STANDARDS) OR FAR 22.406-3 (CONSTRUCTION WAGE RATE REQUIREMENTS))
THE INTERESTED PARTIES AGREE AND THE CONTRACTING OFFICER RECOMMENDS APPROVAL BY THE WAGE AND HOUR DIVISION. AVAILABLE
INFORMATION AND RECOMMENDATIONS ARE ATTACHED.
THE INTERESTED PARTIES CANNOT AGREE ON THE PROPOSED CLASSIFICATION AND WAGE RATE. A DETERMINATION OF THE QUESTION BY THE WAGE
AND HOUR DIVISION IS THEREFORE REQUESTED. AVAILABLE INFORMATION AND RECOMMENDATIONS ARE ATTACHED.
(Send 3 copies to the Department of Labor)
SIGNATURE OF CONTRACTING OFFICER OR REPRESENTATIVE
STANDARD FORM 1444 (REV. 4/2013)
Prescribed by GSA-FAR (48 CFR) 53.222(f)
TITLE AND COMMERCIAL TELEPHONE NUMBER
DATE SUBMITTED
CHECK APPROPRIATE BOX
SERVICE CONTRACT
CONSTRUCTION CONTRACT
AUTHORIZED FOR LOCAL REPRODUCTION
PREVIOUS EDITION IS USABLE
PAPERWORK REDUCTION ACT STATEMENT: Public reporting burden for this collection of information is estimated to average .5 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspects of this collection of information, including suggestions for reducing this burden, to U.S. General Services Administration, Regulatory Secretariat (MVCB)/IC 9000-0089, Office of Governmentwide Acquisition Policy, 1800 F Street, NW, Washington, DC 20405.
OMB Number: 9000-0089
Expiration Date: 9/30/2017
8.2.1.4029.1.523496.503679
CHECK APPROPRIATE BOX. SERVICE CONTRACT: 0
CHECK APPROPRIATE BOX. CONSTRUCTION CONTRACT: 0
2. FROM: (REPORTING OFFICE):
3. CONTRACTOR:
4. DATE OF REQUEST. Enter 2 digit month, 2 digit day and 4 digit year.:
9. DATE OPTION EXERCISED (If APPLICABLE) (SCA ONLY) Enter 2 digit month, 2 digit day and 4 digit year.:
8. DATE CONTRACT WORK STARTED. Enter 2 digit month, 2 digit day and 4 digit year.:
7. DATE OF AWARD. Enter 2 digit month, 2 digit day and 4 digit year.:
6. DATE BID OPENED (SEALED BIDDING) Enter 2 digit month, 2 digit day and 4 digit year.:
5. CONTRACT NUMBER:
10. SUBCONTRACTOR (IF ANY):
11. PROJECT AND DESCRIPTION OF WORK (ATTACH ADDITIONAL SHEET IF NEEDED):
12. LOCATION (CITY, COUNTY AND STATE):
13. IN ORDER TO COMPLETE THE WORK PROVIDED FOR UNDER THE ABOVE CONTRACT, IT IS NECESSARY TO ESTABLISH THE FOLLOWING RATE(S) FOR THE INDICATED CLASSIFICATION(S) NOT INCLUDED IN THE DEPARTMENT OF LABOR DETERMINATION. NUMBER:
13. IN ORDER TO COMPLETE THE WORK PROVIDED FOR UNDER THE ABOVE CONTRACT, IT IS NECESSARY TO ESTABLISH THE FOLLOWING RATE(S) FOR THE INDICATED CLASSIFICATION(S) NOT INCLUDED IN THE DEPARTMENT OF LABOR DETERMINATION. Enter 2 digit month, 2 digit day and 4 digit year.:
13a. LIST IN ORDER: PROPOSED CLASSIFICATION TITLE(S); JOB DESCRIPTION(S); DUTIES; AND RATIONALE FOR PROPOSED CLASSIFICATIONS 1 of 10.:
13c. FRINGE BENEFITS PAYMENTS:
13b. WAGE RATE(S):
13a. LIST IN ORDER: PROPOSED CLASSIFICATION TITLE(S); JOB DESCRIPTION(S); DUTIES; AND RATIONALE FOR PROPOSED CLASSIFICATIONS 9 of 10.:
13c. FRINGE BENEFITS PAYMENTS:
13b. WAGE RATE(S):
13a. LIST IN ORDER: PROPOSED CLASSIFICATION TITLE(S); JOB DESCRIPTION(S); DUTIES; AND RATIONALE FOR PROPOSED CLASSIFICATIONS 10 of 10.:
13c. FRINGE BENEFITS PAYMENTS:
13b. WAGE RATE(S):
13a. LIST IN ORDER: PROPOSED CLASSIFICATION TITLE(S); JOB DESCRIPTION(S); DUTIES; AND RATIONALE FOR PROPOSED CLASSIFICATIONS 8 of 10.:
13c. FRINGE BENEFITS PAYMENTS:
13b. WAGE RATE(S):
13a. LIST IN ORDER: PROPOSED CLASSIFICATION TITLE(S); JOB DESCRIPTION(S); DUTIES; AND RATIONALE FOR PROPOSED CLASSIFICATIONS 7 of 10.:
13c. FRINGE BENEFITS PAYMENTS:
13b. WAGE RATE(S):
13a. LIST IN ORDER: PROPOSED CLASSIFICATION TITLE(S); JOB DESCRIPTION(S); DUTIES; AND RATIONALE FOR PROPOSED CLASSIFICATIONS 6 of 10.:
13c. FRINGE BENEFITS PAYMENTS:
13b. WAGE RATE(S):
13a. LIST IN ORDER: PROPOSED CLASSIFICATION…
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