Attachment III - DHS_Form_700-5.pdf

DEPARTMENT OF HOMELAND SECURITY

CONTRACTOR REPORT OF GOVERNMENT PROPERTY

OMB Control No. 1600-0002 Expiration Date 09/30/2007

OMB STATEMENT: This collection of information is mandatory and will be used to fulfill the requirements of the Homeland Security Acquisition Regulation (HSAR). Public reporting burden is estimated to average 1 hour 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 this burden, to the FAR Secretariat (VRS), Office of Federal Acquisition and Regulatory Policy, GSA, Washington, D.C. 20405; and to the Office of Management and Budget, Information and Regulatory Offices, 725 17th Street, NW, Washington, DC 20503. Please note that an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this collection is 1600-0002.

1. Contract Number:

2. Report Period Ending:

3. Contractor (Name and Address)

4. Contracting Office (Name and Address)

5. Name and location of Government owned, Contractor-Operated Plant (if applicable)

6. Any Government property located at a subcontractor’s plant? YES NO If yes, give the name and address of the subcontractor(s) on an attached sheet to this report.

7. Date contractor’s property control system approved?

8. Approved by whom?

Starting Balance Ending Balance 9.

Property Class

(see Far 45.5)

Total Acquisition

Cost (in dollars)

Total Quantity

(in acres or units)

Items Added

Items Deleted

(in dollars)

Total Acquisition

Cost

Total Quantity

(in acres or units) a

Land & Rights therein b

Other Real Property c

Plant Equipment d

Special Test Equipment e

Special Tooling

f. Materials in Stock (when total value exceeds $50,000)

NOTE: This report shall include all Government Property (i.e. property furnished by the Government, or acquired or fabricated by the contractor or subcontractor). By signature hereon, the contractor’s property administrator declares that the report was prepared from the contractor’s records that are required by FAR 45.5.

10. Contractor Property Administrator ( Type name)

11. Signature Date

DHS Form 700-5 (7/03) Authorized for Local Reproduction