OS-501.pdf

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Attached to
D-11 Districtwide Graffiti Removal Services
Solicitation number
6100088802
Issued by
Allegheny County, Pennsylvania

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OS-501 Confirmation of Service Form Summary

The OS-501 is a confirmation of service form used by the Pennsylvania Department of Transportation (PennDOT) to document and approve vendor services rendered under existing purchase orders. The form serves as the official record that services have been satisfactorily received and payment authorization documentation. Vendors are required to complete the form by providing service dates, vendor contact information, the purchase order number, SAP vendor number, and a complete address. The form requires itemized line-by-line documentation of services performed, including PO line numbers, descriptions, quantities, units of measure, unit prices, and calculated totals for each item billed.

The completion workflow involves three key approval stages: the vendor first submits the completed and signed form to the appropriate PennDOT project manager for verification and payment approval; the project manager then forwards the form to the Goods Receiver, who enters a Goods Receipt in SAP within 48 hours of receipt and provides the SRM Confirmation Number or R3 Material Document Number; finally, the Goods Receiver returns a copy of the fully signed and dated form to the project manager for placement in the procurement file. All information entered on the form must exactly match the corresponding details on the fully executed purchase order, and vendors must provide their signatures and dates to certify the accuracy of submitted information.

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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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