OS-501 (1) (4).pdf

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Attached to
Susq/Wyom Secondary Herbicide Services State and local contract opportunity
Solicitation number
6100065047
Issued by
Lackawanna County, Pennsylvania

About this file

Written by GovTribe AI ·

This is a Confirmation of Service form (OS-501) issued by the Pennsylvania Department of Transportation (PennDOT) for documenting the receipt and approval of services rendered by vendors under executed purchase orders. The form is used to confirm that roadside pesticide and herbicide spraying services for Susquehanna and Wyoming County roads have been satisfactorily completed in accordance with PennDOT's Maintenance Manual guidelines. The document serves as the official record linking the vendor's delivered services to the specific line items on the purchase order, capturing details such as service dates, quantities, units of measure, and pricing for each item provided.

The OS-501 form functions as a three-step approval and payment authorization process: the vendor completes and submits the form to the appropriate PennDOT representative, who certifies satisfactory receipt and approves payment; the Goods Receiver then enters a corresponding Goods Receipt in SAP within 48 hours and provides the SRM Confirmation or R3 Material Document Number; and finally, a completed copy is placed in the procurement file. Vendors must enter information exactly as it appears on the fully executed purchase order, including the ten-digit purchase order number, six-digit SAP vendor number, and precise descriptions of products or services from the purchase order line items. The form accommodates multiple line items across two pages with separate columns for PO line numbers, descriptions, quantities, units of measure, unit prices, and calculated item totals, ensuring accurate documentation and processing of payment for services rendered.

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Other files for this state and local contract opportunity

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File Type Posted
2026 Susquehanna and Wyoming Secondary Herbicide Contract Specs_FINAL PDF.pdf PDF
Domestic Utilization Form (1).pdf PDF
Trade Secret Form (2).pdf PDF
Worker Protection and Investment Cert Form (BOP 2201).docx DOCX document
Terms and Conditions Suq.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:

File details come from the government source that posted it. Updated .