Attachment_5-_DHS_Form_700-03.pdf

DEPARTMENT OF HOMELAND SECURITY

CONTRACTOR'S RELEASE

OMB Control No. 1600-0002 Expiration Date 06/30/2018

PRA Burden 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 Office of the Chief Procurement Officer, Acquisitions Policy and Legislation, Department of Homeland Security, Washington, DC 20528. 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 and it expires 06/30/2018.

ENTER SUM OF TOTAL AMOUNTS

PAID AND PAYABLE

CONTRACTOR (Name and Address)

CONTRACT NO. $

Pursuant to the terms of the above numbered contract and in consideration of the sum stated above, which has been paid or is to be paid to the Contractor, or its assignees, the Contractor, upon payment of the said sum by the UNITED STATES OF AMERICA (hereinafter called the Government), does remise, release, and discharge the Government, its officers, agents, and employees, of and from all liabilities, obligations, claims, and demands whatsoever under or arising from the said contract, except:

1. Specified claims in stated amounts or in estimated amounts where the amounts are not susceptible of exact statement by the Contractor, as follows: (or state "None")

2. Claims, together with reasonable expenses incidental thereto, based upon the liabilities of the Contractor to third parties arising out of the performance of this contract, which are not known to the Contractor on the date of the execution of this release and of which the Contractor gives notice in writing to the Contracting Officer within the period specified in the said contract; and

3. Claims for reimbursement of costs (other than expenses of the Contractor by reason of his indemnification of the Government against patent liability) including reasonable expenses incidental thereto, incurred by the Contractor under any provisions of the said contract relating to patents.

The Contractor agrees, in connection with patent matters and with claims which are not released as set forth above, that it will comply with all provisions of the said contract, including without limitation those provisions relating to notification to the Contracting Officer and relating to the defense or prosecution of litigation.

IN WITNESSES WHEREOF, this release has been executed this day of

(Contractor)

BY

TITLE

NOTE: In the case of a corporation, witnesses are not required but the statement below must be completed.

I, , am the secretary of the corporation named as Contractor in the foregoing release; that who signed said release on behalf of the Contractor was then of said corporation; release was duly signed for and in behalf of said corporation by authority of its governing body and is within the scope of its corporate powers.

(CORPORATE SEAL)

(Signature)

DHS Form 700-3 (12/07) Authorized for Local Reproduction

Contractor's Release, December 2007 D:20050118162331- 05'00' D:20050922171304- 04'00' U.S. Department of Homeland Security, Acquisition Policy and Legislation

DEPARTMENT OF HOMELAND SECURITY

CONTRACTOR'S RELEASE

OMB Control No. 1600-0002 Expiration Date 06/30/2018 PRA Burden 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 Office of the Chief Procurement Officer, Acquisitions Policy and Legislation, Department of Homeland Security, Washington, DC 20528. 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 and it expires 06/30/2018.

ENTER SUM OF TOTAL AMOUNTS PAID AND PAYABLE

CONTRACTOR (Name and Address)

CONTRACT NO.

Pursuant to the terms of the above numbered contract and in consideration of the sum stated above, which has been paid or is to be paid to the Contractor, or its assignees, the Contractor, upon payment of the said sum by the UNITED STATES OF AMERICA (hereinafter called the Government), does remise, release, and discharge the Government, its officers, agents, and employees, of and from all liabilities, obligations, claims, and demands whatsoever under or arising from the said contract, except:

1. Specified claims in stated amounts or in estimated amounts where the amounts are not susceptible of exact statement by the Contractor, as follows: (or state "None")

2. Claims, together with reasonable expenses incidental thereto, based upon the liabilities of the Contractor to third parties arising out of the performance of this contract, which are not known to the Contractor on the date of the execution of this release and of which the Contractor gives notice in writing to the Contracting Officer within the period specified in the said contract; and

3. Claims for reimbursement of costs (other than expenses of the Contractor by reason of his indemnification of the Government against patent liability) including reasonable expenses incidental thereto, incurred by the Contractor under any provisions of the said contract relating to patents.

The Contractor agrees, in connection with patent matters and with claims which are not released as set forth above, that it will comply with all provisions of the said contract, including without limitation those provisions relating to notification to the Contracting Officer and relating to the defense or prosecution of litigation.

IN WITNESSES WHEREOF, this release has been executed this day of (Contractor)

BY

TITLE

NOTE: In the case of a corporation, witnesses are not required but the statement below must be completed.

I, , am the secretary of the corporation named as Contractor in the foregoing release; that who signed said release on behalf of the Contractor was then of said corporation; release was duly signed for and in behalf of said corporation by authority of its governing body and is within the scope of its corporate powers.

(CORPORATE SEAL)

(Signature) DHS Form 700-3 (12/07) Authorized for Local Reproduction