D030_Contractor_Payment-Check_Issue_Data.pdf
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- HT9402-13-R-0001
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Defense Health Agency
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CDRL D030
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DD FORM 1423-1, FEB 2001
CONTRACT DATA REQUIREMENTS LIST
(1 Data Item)
PREVIOUS EDITION MAY BE USED.
Form Approved OMB No. 0704-0188
The public reporting burden for this collection of information is estimated to average 110 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 aspect of this collection of information, including suggestions for reducing the burden, to the Department of Defense, Executive Services and Communications Directorate (0704-0188). 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. Please do not return your form to the above organization. Send completed form to the Government Issuing Contracting Officer for the Contract/PR No. listed in Block E.
A. CONTRACT LINE ITEM NO. B. EXHIBIT C. CATEGORY:
TDP ________ TM _______ OTHER
D. SYSTEM/ITEM E. CONTRACT/PR NO. F. CONTRACTOR
1. DATA ITEM NO. 2. TITLE OF DATA ITEM 3. SUBTITLE
4. AUTHORITY (Data Acquisition Document No.) 5. CONTRACT REFERENCE 6. REQUIRING OFFICE
7. DD 250 REQ
8. APP CODE
9. DIST STATEMENT
REQUIRED
10. FREQUENCY
11. AS OF DATE
12. DATE OF FIRST SUBMISSION
13. DATE OF SUBSEQUENT
SUBMISSION
14. DISTRIBUTION
a. ADDRESSEE
b. COPIES
Draft Final
Reg Repro
15. TOTAL
16. REMARKS
17. PRICE GROUP
18. ESTIMATED
TOTAL PRICE
G. PREPARED BY H. DATE I. APPROVED BY J. DATE
Page of Pages
| T3 TOM-Chpt 3 Addendum A 3-A-8 Payment-Check Issue Report.pdf |
| Data Submission Format |
| 1_DATA_ITEM_NO: D030 |
| 2_TITLE_OF_DATA_ITEM: Contractor Payment/Check Issue Data |
| 3_SUBTITLE: |
| 4_AUTHORITY_Data_Acquisit: N/A |
| 5_CONTRACT_REFERENCE: G.11.3.3; G.11.6; G.11.7; G.11.8 |
| 6_REQUIRING_OFFICE: TMA-CRM |
| 7_DID_250_REQ: NO |
| 8_APP_CODE: N/A |
| DIST_STATEMENT: B |
| 10_FREQUENCY: See Block 16 |
| 11_AS_OF_DATE: O |
| 12_DATE_OF_FIRST_SUBMISSI: See Block 16 |
| 13_DATE_OF_SUBSEQUENT_SUB: See Block 16 |
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| 16_REMARKS: Block 10 - Required with each cycle. Most cycles are competed daily. |
Block 12 - Report will be required upon the start of claims processing Block 13 - Required with each cycle.
The contractor shall provide a Contractor Payment/Check Issue Report indicating payments issued for each cycle or each approved manual release. The occurrence of this report is based on cycle which is normally daily based on normal work days. Voided/Staledated payments must also be reported as negative amounts in this same format. Reference Attachment A to this CDRL.
| 17_PRICE_GROUP: |
| ESTIMATED_TOTAL_PRICE: |
| G_PREPARED_BY: Evelyn Young |
| H_DATE: 8/2/2013 |
| 1_APPROVED_BY: Bill Blanche |
| J_DATE: 8/20/2013 |
| Page: |
| reg38t: 0 |
| A_CONTRACT_LINE_ITEM_NO: X015 |
| B_EXHIBIT: Exhibit A |
| TDP: |
| TM: |
| OTHER: |
| DSYSTEMITEM: TRICARE Pharmacy Program |
| E_CONTRACTPR_NO: |
| FCONTRACTOR: |
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| Reset: |
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