Attach_1_APPENDIX_D_OAWR_FORM.doc

N00019-15-R-0089 Appendix D

27 May 2015

OVER AND ABOVE WORK REQUEST FORM PRIVATE

To:

Procuring/Administrative Contracting Officer

Via:

COR

Subj:

Request for Authorization to Proceed with an Over and Above Work Requirement Ref:

(a) _________________________________________(Device/Site)

1. The undersigned Contractor requests authorization to proceed with an over and above work requirement under Item __________ of Contract _________________, Task Order ________ in accordance with the Over and Above Work clause of the contract as described below:

Needed Repairs:

Corrective Action Required:

Estimated Man-Hours:

Estimated Cost:

Estimated Duration:

Detailed cost breakdown:

· submit on separate sheet

· include necessary parts and materials SUBMITTED BY: (Contractor)

REVIEWED BY: (COR)

Signature/Date

Signature/Date

COR Recommend:

[ ] Approval

[ ] Disapproval

2.

PCO/ACO:

[ ] Approved

[ ] Disapproved for the following reason(s)

CONTRACTING OFFICER

DATE