OS-501 (1) (4).pdf

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Attached to
Interstate Secondary Herbicide Services State and local contract opportunity
Solicitation number
6100065044
Issued by
Lackawanna County, Pennsylvania

About this file

Written by GovTribe AI ·

This is a Confirmation of Service form (OS-501) used by PennDOT (Pennsylvania Department of Transportation) to document and authorize payment for services rendered by vendors under purchase orders. The form serves as the official record that services have been satisfactorily received and provides the mechanism for processing vendor payment through PennDOT's SAP accounting system. Vendors complete the form by entering service dates, their company information, purchase order number, SAP vendor number, and complete address details. The form itemizes services or products delivered by line item, requiring vendors to reference the exact descriptions from the executed purchase order and document quantities, units of measure, unit prices, and calculated totals. The form accommodates multiple page entries for purchase orders containing numerous line items. PennDOT's Project Manager reviews and approves the form by certifying satisfactory service receipt, after which the Goods Receiver enters a corresponding Goods Receipt in SAP within 48 hours and provides the SRM Confirmation Number or R3 Material Document Number. A copy of the fully completed and signed form is then placed in the procurement file.

The OS-501 form requires that all vendor information and line item descriptions be entered exactly as they appear on the fully executed purchase order to ensure accuracy and proper tracking. The form is designed to be completed electronically via email and forwarded through the approval chain, beginning with the vendor's signature and submission to the appropriate PennDOT representative. Required fields are marked with asterisks and include vendor name, phone number, purchase order number, SAP vendor number, complete address, unit of measure, and unit price. The form includes space for totals from multiple pages, with a grand total calculation at the end. This administrative document is essential for PennDOT's internal controls and vendor payment processing but does not itself establish contract terms, pricing, or service scope—those details are contained within the referenced purchase order.

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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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