OS-501 Confirmation of Services Form.pdf

805 KB Posted

Attached to
PA DEP Certified Drinking Water Operator
Solicitation number
6100064463
Issued by
Fulton County, Pennsylvania

About this file

Written by GovTribe AI ·

The document is a Pennsylvania Department of Transportation (PennDOT) Confirmation of Service form (OS-501), which is an internal administrative document used to verify and process vendor service payments. The form is a blank template with detailed instructions for completing each section, including fields for vendor information, purchase order details, service dates, quantities, unit prices, and confirmation signatures from both the vendor and PennDOT representatives.

The instructions outline a multi-step process for completing the form, which involves the vendor filling out the service details, a PennDOT representative confirming satisfactory service receipt and approving payment, and a Goods Receiver certifying the goods receipt in SAP and providing a confirmation number. The form requires precise data entry matching the fully executed purchase order, with specific guidance on how to document line items, quantities, unit of measure, and pricing. The document emphasizes the importance of accurate documentation for internal procurement and payment processing.

View the file

Other files

File Type Posted
PA DEP CERTIFIED DRINKING WATER OP SITE VISIT 08.18.25.doc DOC document
Domestic Utilization Form.pdf PDF
PA DEP Certified Drinking Water Operator SOW FINAL 09.03.25.pdf PDF
PA DEP Public Water Supply Permit - Site B - January 2025.pdf PDF
Terms and Conditions.pdf PDF
Trade Secret Form.pdf PDF
OS-52 (3.14.16).pdf PDF
Worker Protection Form BOP FINAL.pdf PDF

On GovTribe

Work with this file

  • Download the original file
  • Contacts named in this file
  • Similar government files
  • Ask GovTribe AI about this file
Try for free Login

Text version

The file's text, extracted by GovTribe without its formatting.

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.

Item #, Row 1:
0:
1:
2:
3:
4:
5:
6:
7:
8:
9:
10:
11:
12:
13:
14:
15:
16:
17:
18:
19:
20:
21:
22:
23:
24:
25:
0:
1:
2:
3:
4:
5:
6:
7:
8:
9:
10:
11:
12:
13:
14:
15:
16:
17:
18:
19:
20:
21:
22:
23:
24:
25:
26:
27:
28:
29:
30:
31:
32:
33:
34:
35:
36:
37:
38:
39:
40:
41:
42:
43:
44:
ItemTotal1:
0: 0
1: 0
2: 0
3: 0
4: 0
5: 0
6: 0
7: 0
8: 0
9: 0
10: 0
11: 0
12: 0
13: 0
14: 0
15: 0
16: 0
17: 0
18: 0
19: 0
20: 0
21: 0
22: 0
23: 0
24: 0
25:
0: 0
1: 0
2: 0
3: 0
4: 0
5: 0
6: 0
7: 0
8: 0
9: 0
10: 0
11: 0
12: 0
13: 0
14: 0
15: 0
16: 0
17: 0
18: 0
19: 0
20: 0
21: 0
22: 0
23: 0
24: 0
25: 0
26: 0
27: 0
28: 0
29: 0
30: 0
31: 0
32: 0
33: 0
34: 0
35: 0
36: 0
37: 0
38: 0
39: 0
40: 0
41: 0
42: 0
43: 0
44: 0
Description Product ID, Row 1:
0:
1:
2:
3:
4:
5:
6:
7:
8:
9:
10:
11:
12:
13:
14:
15:
16:
17:
18:
19:
20:
21:
22:
23:
24:
25:
0:
1:
2:
3:
4:
5:
6:
7:
8:
9:
10:
11:
12:
13:
14:
15:
16:
17:
18:
19:
20:
21:
22:
23:
24:
25:
26:
27:
28:
29:
30:
31:
32:
33:
34:
35:
36:
37:
38:
39:
40:
41:
42:
43:
44:
Quantity 1:
0:
1:
2:
3:
4:
5:
6:
7:
8:
9:
10:
11:
12:
13:
14:
15:
16:
17:
18:
19:
20:
21:
22:
23:
24:
25:
0:
1:
2:
3:
4:
5:
6:
7:
8:
9:
10:
11:
12:
13:
14:
15:
16:
17:
18:
19:
20:
21:
22:
23:
24:
25:
26:
27:
28:
29:
30:
31:
32:
33:
34:
35:
36:
37:
38:
39:
40:
41:
42:
43:
44:
UOM, Row 1:
0:
1:
2:
3:
4:
5:
6:
7:
8:
9:
10:
11:
12:
13:
14:
15:
16:
17:
18:
19:
20:
21:
22:
23:
24:
25:
0:
1:
2:
3:
4:
5:
6:
7:
8:
9:
10:
11:
12:
13:
14:
15:
16:
17:
18:
19:
20:
21:
22:
23:
24:
25:
26:
27:
28:
29:
30:
31:
32:
33:
34:
35:
36:
37:
38:
39:
40:
41:
42:
43:
44:
Unit Price 1:
0:
1:
2:
3:
4:
5:
6:
7:
8:
9:
10:
11:
12:
13:
14:
15:
16:
17:
18:
19:
20:
21:
22:
23:
24:
25:
0:
1:
2:
3:
4:
5:
6:
7:
8:
9:
10:
11:
12:
13:
14:
15:
16:
17:
18:
19:
20:
21:
22:
23:
24:
25:
26:
27:
28:
29:
30:
31:
32:
33:
34:
35:
36:
37:
38:
39:
40:
41:
42:
43:
44:
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 .