Attachment_4_DD250.pdf

Form Approved OMB No. 0704-0248MATERIAL INSPECTION AND RECEIVING REPORT

PLEASE DO NOT RETURN YOUR COMPLETED FORM TO THE ABOVE ADDRESS.

SEND THIS FORM IN ACCORDANCE WITH THE INSTRUCTIONS CONTAINED IN THE DFARS, APPENDIX F-401.

16. STOCK/PART NO.

21. CONTRACT QUALITY ASSURANCE 22. RECEIVER'S USE

15.

ITEM NO.

17. QUANTITY

SHIP/REC'D*

18.

UNIT

19.

UNIT PRICE

20.

AMOUNT

DESCRIPTION

(Indicate number of shipping containers - type of container - container number.)

a. ORIGIN b. DESTINATION

CQA ACCEPTANCE of listed items has has been made by me or under my supervision and they conform to contract, except as noted herein or on supporting documents.

been made by me or under my supervision and they conform to contract, except as noted herein or on supporting documents.

DATE SIGNATURE OF AUTHORIZED

GOVERNMENT REPRESENTATIVE

DD FORM 250, AUG 2000

23. CONTRACTOR USE ONLY

DATE RECEIVED

Quantities shown in column 17 were received in apparent good condition except as noted.

PREVIOUS EDITION IS OBSOLETE

CQA ACCEPTANCE of listed items

DATE

1. PROCUREMENT INSTRUMENT IDENTIFICATION

(CONTRACT) NO.

6. INVOICE NO./DATE 7. PAGE OF 8. ACCEPTANCE POINT

2. SHIPMENT NO. 3. DATE SHIPPED 4. B/L

TCN

5. DISCOUNT TERMS

9. PRIME CONTRACTOR CODE 10. ADMINISTERED BY CODE

11. SHIPPED FROM (If other than 9) CODE 12. PAYMENT WILL BE MADE BY CODE

13. SHIPPED TO CODE 14. MARKED FOR CODE

FOB:

ORDER NO.

* If quantity received by the Government is the same as quantity shipped, indicate by (X) mark; if different, enter actual quantity received below quantity shipped and encircle.

TYPED NAME:

TITLE:

MAILING ADDRESS:

COMMERCIAL TELEPHONE

NUMBER:

TYPED NAME:

TITLE:

MAILING ADDRESS:

COMMERCIAL TELEPHONE

NUMBER:

TYPED NAME:

TITLE:

MAILING ADDRESS:

COMMERCIAL TELEPHONE

NUMBER:

SIGNATURE OF AUTHORIZED

GOVERNMENT REPRESENTATIVE

SIGNATURE OF AUTHORIZED

GOVERNMENT REPRESENTATIVE

The public reporting burden for this collection of information is estimated to average 30 minutes 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 aspect of this collection of information, including suggestions for reducing the burden, to Department of Defense, Washington Headquarters Services, Directorate for Information Operations and Reports (0704-0248), 1215 Jefferson Davis Highway, Suite 1204, Arlington, VA 22202-4302. Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number.