OS-501 (1) (4).pdf

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Attached to
Luzerne Secondary Herbicide Services
Solicitation number
6100065045
Issued by
Luzerne County, Pennsylvania

About this file

Written by GovTribe AI ·

This is a Confirmation of Service form (OS-501) used by the Pennsylvania Department of Transportation (PennDOT) to document and approve vendor payment for services rendered under purchase orders. The form serves as the official record that services or materials listed on a PO have been satisfactorily received and delivered. The document is specifically applicable to the Luzerne County Secondary Herbicide Services contract, which requires roadside pesticide and herbicide spraying services performed in accordance with PennDOT's Maintenance Manual guidelines. Vendors complete the form by providing service dates, their company information, purchase order number, SAP vendor number, and a complete itemized breakdown of services delivered, including line item numbers, descriptions, quantities, units of measure, unit prices, and item totals. The form accommodates multiple line items across two pages to account for various services or materials delivered during the billing period.

The OS-501 form establishes a three-step approval workflow for payment authorization. The vendor initiates the process by completing and signing the form with the date services were rendered, then submitting it to the appropriate PennDOT Project Manager for approval. The Project Manager verifies satisfactory receipt and approves payment by signing and dating the form before forwarding it to the Goods Receiver. The Goods Receiver completes the final step by certifying that a Goods Receipt entry has been made in PennDOT's SAP system within 48 hours of service receipt, as required by Management Directive 310.31, and provides the SRM Confirmation Number or R3 Material Document Number. All information entered on the form must match exactly as it appears on the fully executed Purchase Order, and the completed, signed form is then filed in the procurement record.

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Other files

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Trade Secret Form (2).pdf PDF
2026 Luzerne Secondary Herbicide Contract Specs_FINAL PDF.pdf PDF
Terms and Conditions Luzern.pdf PDF
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OS-501 (7-16)

CONFIRMATION OF SERVICE

www.penndot.gov

Date(s) Service Rendered:________________ - _______________ Vendor Name: __________________________________________ Phone: ________________________________________________

PURCHASE ORDER #:___________________________________

SAP Vendor Number:_____________________________________ Address (1): ____________________________________________ Address (2): ____________________________________________ City: ____________________ State: _______ Zip Code: ________

(Reference line items on purchase order that match the services that were performed.)

PO Line # Description / Product ID Quantity U.O.M. Unit Price Item Total

PENNDOT USE ONLY

I certify the services represented by the confirmation of service form above were received satisfactorily. Therefore, I approve payment be made.

Project Manager Signature Date (mm/dd/yyyy)

I certify that I have entered a Goods Receipt in SAP for this service. This should occur within 48 hours of receipt (per Management Directive 310.31).

SRM/R3 Receiver Signature Date (mm/dd/yyyy) SRM Confirmation # / R3 Material Document #

Vendor Signature:_______________________________________________________________ Date:__________________________

Total of Page 1 Total of Page 2 Grand Total

Continued on page 2

PO Line # Description / Product ID Quantity U.O.M. Unit Price Item Total

Total of Page 1 Total of Page 2 Grand Total

Instructions:

Complete the OS-501 form in accordance with the instructions below.

1. The Vendor completes the OS-501 form, then forwards the signed/dated form to the appropriate PennDOT representative for approval (may be done electronically via email). Explanations for fields on the form are listed below.

Date Service Rendered: Provide the date of service (i.e., Date or date range).

Vendor Name*: Enter name.

Phone*: Area code and phone number.

PURCHASE ORDER #*: The ten digit number in the upper right corner.

SAP Vendor Number*: This is the vendor’s six digit vendor number (e.g. 412345).

Address (1)*: Vendor's street address.

Address (2)*: Enter the Floor, Suite, etc. of the vendors address, if applicable.

City*: Vendor's City.

State*: Vendor's State.

Zip Code*: Vendor's Zip Code.

PO Line #: Enter the PO line item number(s) in this column. Many PO’s contain numerous line items.

Use separate lines to account for each item that was delivered.

Description/Product ID*: Enter the exact description from the PO line item Description/Product ID column.

Quantity: Enter the quantity delivered for the time period.

U.O.M.*: This is the unit of measure for the service/material rendered (e.g. hours, days, number, etc).

Unit Price*: Cost per individual unit of measure.

Total: Calculated Amount of the Quantity x Unit Price.

*Enter information exactly as it appears on the fully executed Purchase Order.

2. The PennDOT Representative confirms services were received satisfactorily and approves payment to be made by signing and dating on the “Project Manager Signature” line. The PennDOT Representative forwards the signed/dated form to their Goods Receiver.

3. The Goods Receiver certifies that a Goods Receipt has been entered in SAP for the by signing, dating, and providing the SRM Confirmation Number/R3 Material Document Number.

4. The Goods Receiver provides a copy of the completed and signed/dated form to the PennDOT Representative for placement in the Procurement file.

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PURCHASE ORDER:
Contractor Name:
Phone:
SAP Vendor Number:
Check Box3: Off
Date:
Date mmddyyyy:
Confirmation Number:
Date mmddyyyy_2:
Total Page 1: 0
Total Page 2: 0
Grand Total: 0
Date Service Rendered:
Date Service Rendered2:
Address 1:
Address 2:
City:
State:
Zip Code:

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