Attachment J-9 - SF 1413 - Statement of Acknowledgement .pdf
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Attachment J-9 Statement and Acknowledgement Standard Form 1413 (Rev 6-89
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STATEMENT AND ACKNOWLEDGMENT OMB No.: 9000-0014 Expires: 4/30/2008
Public reporting burden for this collection of information is estimated to average 30 minutes 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, (VIR), Regulatory and Federal Assistance Division, GSA, Washington, DC 20405; and to the Office of Management and Budget, Paperwork Reduction Project (9000-0014), Washington, DC 20503.
PART I - STATEMENT OF PRIME CONTRACTOR
1. PRIME CONTRACT NO. 2.DATE SUBCONTRACT
AWARDED
3. SUBCONTRACT NUMBER
15b. TITLE OF PERSON SIGNING
AUTHORIZED FOR LOCAL REPRODUCTION
PREVIOUS EDITION IS NOT USABLE
STANDARD FORM 1413 (REV. 7/2005)
Prescribed by GSA/FAR (48 CFR) 53.222(e)
4. PRIME CONTRACTOR 5. SUBCONTRACTOR
a. NAME a. NAME
b. STREET ADDRESS b. STREET ADDRESS
c. CITY d. STATE e. ZIP CODE c. CITY d. STATE e. ZIP CODE
6. The prime contract does, does not contain the clause entitled "Contract Work Hours and Safety Standards Act -- Overtime Compensation."
7. The prime contractor states that under the contract shown in Item 1, a subcontract was awarded on the date shown in Item 2 to the subcontractor identified in item 5 by the following firm:
a. NAME OF AWARDING FIRM
b. DESCRIPTION OF WORK BY SUBCONTRACTOR
8. PROJECT 9. LOCATION
10a. NAME OF PERSON SIGNING 11. BY (Signature) 12. DATE SIGNED
10b. TITLE OF PERSON SIGNING
PART II - ACKNOWLEDGMENT OF SUBCONTRACTOR
13. The subcontractor acknowledges that the following clauses of the contract shown in Item 1 are included in this subcontract:
Contract Work Hours and Safety Standards Act - Overtime Compensation - (If included in prime contract see Block 6)
Payrolls and Basic Records Withholding of Funds Disputes Concerning Labor Standards Compliance with Davis-Bacon and Related Act Regulations
Davis-Bacon Act Apprentices and Trainees Compliance with Copeland Act Requirements Subcontracts (Labor Standards) Contract Termination - Debarment Certification of Eligibility
14. NAME(S) OF ANY INTERMEDIATE SUBCONTRACTORS, IF ANY
A C
B D
15a. NAME OF PERSON SIGNING 16. BY (Signature) 17. DATE SIGNED
1.6 Presentation Agent PDFlib 3.02 (C++/Win32) D:20050617125503-04'00' D:20080212101247-05'00'
STATEMENT AND ACKNOWLEDGMENT
OMB No.:
9000-0014 Expires:
4/30/2008 Public reporting burden for this collection of information is estimated to average 30 minutes 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, (VIR), Regulatory and Federal Assistance Division, GSA, Washington, DC 20405; and to the Office of Management and Budget, Paperwork Reduction Project (9000-0014), Washington, DC 20503.
PART I - STATEMENT OF PRIME CONTRACTOR
1. PRIME CONTRACT NO.
2.DATE SUBCONTRACT
AWARDED
3. SUBCONTRACT NUMBER
15b. TITLE OF PERSON SIGNING
AUTHORIZED FOR LOCAL REPRODUCTION
PREVIOUS EDITION IS NOT USABLE
STANDARD FORM 1413
(REV. 7/2005)
Prescribed by GSA/FAR (48 CFR) 53.222(e)
4. PRIME CONTRACTOR
5. SUBCONTRACTOR
a. NAME
a. NAME
b. STREET ADDRESS
b. STREET ADDRESS
c. CITY
d. STATE
e. ZIP CODE
c. CITY
d. STATE
e. ZIP CODE
6. The prime contract does, does not contain the clause entitled "Contract Work Hours and Safety Standards Act -- Overtime Compensation."
7. The prime contractor states that under the contract shown in Item 1, a subcontract was awarded on the date shown in Item 2 to the subcontractor identified in item 5 by the following firm:
a. NAME OF AWARDING FIRM
b. DESCRIPTION OF WORK BY SUBCONTRACTOR
8. PROJECT
9. LOCATION
10a. NAME OF PERSON SIGNING
11. BY
(Signature)
12. DATE SIGNED
10b. TITLE OF PERSON SIGNING
PART II - ACKNOWLEDGMENT OF SUBCONTRACTOR
13. The subcontractor acknowledges that the following clauses of the contract shown in Item 1 are included in this subcontract:
Contract Work Hours and Safety Standards Act - Overtime Compensation - (If included in prime contract see Block 6) Payrolls and Basic Records Withholding of Funds Disputes Concerning Labor Standards Compliance with Davis-Bacon and Related Act Regulations Davis-Bacon Act Apprentices and Trainees Compliance with Copeland Act Requirements Subcontracts (Labor Standards) Contract Termination - Debarment Certification of Eligibility
14. NAME(S) OF ANY INTERMEDIATE SUBCONTRACTORS, IF ANY
A C B D 15a. NAME OF PERSON SIGNING
16. BY
(Signature)
17. DATE SIGNED
| Part 1 - Statement of Prime Contractor 1 Prime Contract Number: |
| Part 1 Statement of Prime Contractor 2 Date Subcontract Awarded: |
| Part 1 Statement of Prime Contractor 3 Subcontract Number: |
| Part 1 Statement of Prime Contractor 4 Name of Prime Contractor: |
| Part 1 Statement of Prime Contractor 4 Street Address of Prime Contractor: |
| Part 1 Statement of Prime Contractor 4 City of Prime Contractor: |
| Part 1 Statement of Prime Contractor 4 State of Prime Contractor Two Letter Abbrebviation: |
| Part 1 Statement of Prime Contractor 4 Zip Code of Prime Contractor: |
| Part 1 Statement of Prime Contractor 5 Name of Subcontractor: |
| Part 1 Statement of Prime Contractor 5 Street Address of Subcontractor: |
| Part 1 Statement of Prime Contractor 5 City of Subcontractor: |
| Part 1 Statement of Prime Contractor 5 State of Subcontractor Two Letter Abbreviation: |
| Part 1 Statement of Prime Contractor 5 Zip Code of Subcontractor: |
| Part 1 Statement of Prime Contractor 6 The Prime Contract Does Contain the Clause Entitled Contract Work Hours and Safety Standards Act Overtime Compensation Check Box.: |
| Part 1 Statement of Prime Contractor 6 The Prime Contract Does Not Contain the Clause Entitled Contract Work Hours and Safety Standards Act Overtime Compensation Checkbox: |
| Part 1 Statement of Prime Contractor 7 Name of Awarding Firm: |
| Part 1 Statement of Prime Contractor 7 Description of Work by Subcontractor: |
| Part 1 Statement of Prime Contractor 8 Project: |
| Part 1 Statement of Prime Contractor 9 Location: |
| Part 1 Statement of Prime Contractor 10 Name of Person Signing Statement: |
| Part 1 Statement of Prime Contractor Title of Person Signing Statement: |
| Part 1 Statement of Prime Contractor 12 Date Statement Signed: |
| Part 2 Acknowledgment of Subcontractor 14 Name of Any Intermediate Subcontractors If Any 1: |
| Part 2 Acknowledgment of Subcontractor 14 Name of Any Intermediate Subcontractor If Any 2: |
| Part 2 Acknowledgment of Subcontractor 14 Name of Any Intermediate Subcontractors If Any 3: |
| Part 2 Acknowlegment of Subcontractor 14 Name of Any Intermediate Subcontractors If Any 4: |
| Part 2 Acknowledgment of Subcontractor 15 Name of Person Signing Acknowldgment: |
| Part 2 Acknowledgment of Subcontractor 15 Title of Person Signing Acknowledgment: |
| Part 2 Acknowledgment of Subcontractor 17 Date Acknowledgment Signed: |
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