TSM_CDRL_A003.pdf

CONTRACT DATA REQUIREMENTS LIST

(1 Data Item)

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 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.

TBD

B. EXHIBIT

A

C. CATEGORY:

TDP __ TM _ _ OTHER _X-MISC___

D. SYSTEM/ITEM

TSM W/BACKHAUL COMMS

E. CONTRACT/PR NO.

N00178-14-R-1010

F. CONTRACTOR

TBD

1. DATA ITEM NO.

A003

2. TITLE OF DATA ITEM

CERTIFICATION/DATA REPORT

3. SUBTITLE

Certification of Compliance with Regulatory Requirements

4. AUTHORITY (Data Acquisition Document No.)

DI-MISC-80678 (SEE BLK 16)

5. CONTRACT REFERENCE

C.3.1.5

6. REQUIRING OFFICE

NSWCDD G81

7. DD 250 REQ

LT

9. DIST

STATEMENT

C (SEE BLK

16)

10. FREQUENCY

OTIME

12. DATE OF 1ST SUBMISSION

SEE BLK 16

14. DISTRIBUTION

a. ADDRESSEE

b. COPIES

8. APP CODE

N/A

11. AS OF DATE

N/A

13. DATE OF SUBSEQUENT

SUBMISSION N/A Draft

Final

Reg Repro

16. REMARKS

BLK 4: SECTIONS 10.1, 10.2, 10.2.1, 10.2.4, AND 10.5 ONLY.

BLK 9: DISTRIBUTION STATMENT C: DISTRIBUTION AUTHORIZED TO U.S.

GOVERNMENT AGENCIES AND THEIR CONTRACTORS ONLY ADMINISTRATIVE OR

OPERATIONAL USE [MAR 2014]. OTHER REQUESTS FOR THIS DOCUMENT SHALL

BE REFERRED TO COMMAND, NAVAL SURFACE WARFARE CENTER, DAHLGREN

DIVISION, 4045 HIGLEY ROAD, DAHLGREN, VIRGINIA 22448-5110.

BLK 12: FIRST SUBMISSION DUE AT TIME OF DELIVERY OF TSM TO THE

GOVERNMENT.

BLK 14: ELECTRONIC MEDIA: REPORT SHALL BE SUBMITTED IN MS OFFICE 2007

APPLICATIONS (OR EARLIER) OR ADOBE PDF ATTACHED TO EMAIL TO THE

NSWCDD TPOC AND TO THE CONTRACT SPECIALIST, AS LISTED IN SECTION G,

GOVERNMENT CONTRACT ADMINISTRATION POINTS OF CONTACT AND

RESPONSIBILITIES. ONLY LETTER OF TRANSMITTAL IS REQUIRED TO BE SENT TO

THE CONTRACT SPECIALIST.

NSWCDD G81 TPOC 0 1 0

CS 0 1 0

15. TOTAL --------- 0 2 0

G. PREPARED BY

BRET COONS

H. DATE

3/21/2014

I. APPROVED BY ERIN M. SWARTZ J. DATE

3/21/2014

DD Form 1423-1, FEB 2001 PREVIOUS EDITION MAY BE USED Page _1_ of _1_ Pages

18. ESTIMATED

TOTAL PRICE

17. PRICE

GROUP