OS-501ConfirmationofSvc(Blank).pdf

PDF 513 KB Posted

Attached to
D8 Landscaping/Ground Maintenance Rest Areas 47/48
Solicitation number
6100064864
Issued by
Dauphin 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 process payment for services rendered by vendors. The form serves as the official record that a vendor has completed work according to the terms specified in a purchase order, and it facilitates the payment approval and goods receipt process within PennDOT's SAP accounting system. Vendors are required to complete the form with their company information, service dates, purchase order number, SAP vendor number, and a detailed itemization of services provided, including line item descriptions, quantities, units of measure, unit prices, and total amounts. The form then proceeds through an approval workflow in which the responsible PennDOT Project Manager certifies receipt of satisfactory services, followed by the Goods Receiver's certification that a goods receipt has been entered into SAP within 48 hours of receipt, as mandated by Management Directive 310.31, before final payment authorization.

The form is applicable to the PennDOT District 8 landscaping and grounds maintenance contract for Rest Areas 47 and 48 in Dauphin County, Pennsylvania, which is designated as a Micro Business Reserve set-aside requiring that the awarded contractor be a Department of General Services Certified Micro Business prior to the bid closing date. The Confirmation of Service form accommodates multiple page entries to account for numerous line items and provides spaces for totals from both pages to arrive at a grand total. All vendor information entered on the form must match exactly as it appears on the fully executed purchase order, and the document requires signatures and dates from both the vendor and PennDOT representatives to establish an audit trail for procurement compliance and payment processing.

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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 .