OTHER THAN NEW MATERIAL WORKSHEET Request.doc

CUI

OTHER THAN NEW MATERIAL WORKSHEET

(Request for information and supporting documentation) This information/supporting documentation is part of your quote/offer. It must be submitted on Company letterhead and signed by an agent of the Company.

1. CURRENT ACQUISITION INFORMATION:

Buyer's Name: ______________________________________________________

Solicitation No.: ____________________________________________________

NSN: ________________________________________________________________

Noun: _______________________________________________________________ P/N: ________________________________________________________________ Drawing No./Revision: ___________________________________________

2. SUBMISSION. The submitter shall provide supporting documentation as necessary to demonstrate that the OTHER THAN NEW material offered meets solicitation requirements. Used, reconditioned, or remanufactured items shall not be used unless the Contracting Officer has authorized their use. In order for the Contracting Officer to make that determination, the submitter shall provide certain information along with supporting documentation on or before the date that the quote/offer is due, or within the timeframe specified by the Contracting Officer if additional documentation is requested after submission of the quote/offer.

3. ACQUIRED FROM. Items were acquired as OTHER THAN NEW from one of the following sources:

GOVERNMENT SOURCE

Government (Selling) Agency: _______________________________________

Address: ________________________________________________________________________________________________________________________________________________________________________________________________________________________ Government Contract Number: _________________________________________ Government Contract Date: ____________________________________________

Date Acquired: _______________________________________________________

OTHER THAN A GOVERNMENT SOURCE

Source Obtained From: _______________________________________________

Source Address: ________________________________________________________________________ ________________________________________________________________________________________________________________________________________________

Date Acquired From Source:__________________________________________ Government Contract Number: _______________________________________ Government Contract Date: __________________________________________

4. DESCRIPTION: Check as appropriate and provide information and supporting documentation. For information concerning definitions, please see Federal Acquisition Regulation (FAR) 52.211-5, Material Requirements.

( ) RECONDITIONED

a. Source of Reconditioning: include name of company, address, and phone number.

b. Summary of Reconditioning (provide full details):

( ) RECOVERED MATERIAL:

a. Source of Material:

b. Summary of Material:

( ) REMANUFACTURED:

a. Source of Remanufacture:

b. Summary of Remanufacture:

( ) RESIDUAL INVENTORY:

a. Source:

b. Summary/pertinent information:

( ) UNUSED FORMER GOVERNMENT SURPLUS:

a. Source of surplus material:

b. Summary/pertinent information:

5. ADDITIONAL INFORMATION REQUIRED FOR ALL SUBMISSIONS:

SHELF LIFE. Items being offered to the government that have any associated parts with a shelf life must be identified. Please list those items along with whether or not they have been replaced with new parts.

Item: _____________________________________________________________

Shelf Life: ________________________________________________________

Replacement Date: ______________________________________________

Item: _____________________________________________________________

Shelf Life: ________________________________________________________

Replacement Date: _______________________________________________

Item: _____________________________________________________________

Shelf Life: ________________________________________________________

Replacement Date: _______________________________________________

PACKAGING.

( ) The offered material is in its original package. Describe packaging:

( ) The offered material is not in its original packaging. Describe packaging:

Unless the solicitation states otherwise, submitters of other than new material are authorized to open packages, inspect material, and reseal packages. Each time this is done, the submitter's authorized representative or inspector must sign the packages where they were resealed and annotate the date of inspection.

STORAGE - Items were stored:

1. Outside. State how stored/protected: ________________________________________________________________________________________________________________________________________________

2. Inside. State how stored/protected:

6. SUBMISSION. The submitter, by signing the below, certifies that the above statements are true and correct. Please provide printed name, signature, company address, and phone number where you can be reached. Again, the signer must be an agent of the company.

Signature: ____________________________________________________________

Printed Name: ________________________________________________________

Title: _________________________________________________________________

Company Name: ______________________________________________________

Company Address: ________________________________________________________________________________________________________________________________________________________________________________________________________________________

Phone Number: _______________________________________________________

Cage Code: _______________

Controlled by: DLA Land and Maritime

Controlled by: DLA Land Warren

CUI Category: Privacy/SSEL

Distribution/Dissemination Control: FEDCON

POC: Sabrina.krafft@dla.mil

CUI