SF_1449_-_Mobile_CT_Scanner.pdf

OMB NO. 0990-0115

SOLICITATION / CONTRACT / ORDER FOR COMMERCIAL ITEMS

OFFEROR TO COMPLETE BLOCKS 12, 17, 23, 24 & 30

1. REQUISITION NUMBER

PAGE 1 OF

2. CONTRACT NO.

3. AWARD / EFFECTIVE

DATE

4. ORDER NUMBER

5. SOLICITATION NUMBER

10-18-002-KN

6. SOLICITATION ISSUE

DATE

7. FOR SOLICITATION

INFORMATION CALL:

a. NAME

Kenny Nicholson, Contract Specialist

b. TELEPHONE NUMBER (No collect calls)

(406) 247-7071

8. OFFER DUE DATE /

LOCAL TIME

at

9. ISSUED BY CODE 10. THIS ACQUISITION IS

UNRESTRICTED OR

NAICS: 621493

SIZE STANDARD: $15.00 Million

SET ASIDE: % FOR

SMALL BUSINESS

HUBZONE SMALL BUSINESS

EMERGING SMALL BUSINESS

8(A)

SERVICE-DISABLED VETERAN-

OWNED SMALL BUSINESS

PHS INDIAN HEALTH SERVICE

BILLINGS AREA

OFFICE OF CONTRACTS AND GRANTS

P.O. BOX 36600 / 2900 4TH AVENUE NORTH, ROOM 304

BILLINGS, MONTANA 59107-6600

11. DELIVERY FOR FOB

DESTINATION UNLESS BLOCK IS

MARKED

SEE SCHEDULE

12. DISCOUNT TERMS

IHS NET 30P

13a.

THIS CONTRACT IS A

RATED ORDER UNDER DPAS

(15 CFR 700)

13b. RATING

14. METHOD OF SOLICITATION

RFQ IFB RFP

15. DELIVER TO: CODE 16. ADMINISTERED BY: CODE

17a. CONTRACTOR / OFFEROR CODE FACILITY

CODE

18a. PAYMENT WILL BE MADE BY: CODE

TELEPHONE NO. ( )

PHS Indian Health Service—Billings Area Office of Financial Management—Attention: Eileen Buckman P.O. Box 36600 / 2900 4TH Avenue North, Room 304

Billings, Montana 59107-6600

TELEPHONE NO. (406) 247-7188

17.b. CHECK IF REMITTANCE IS DIFFERENT AND PUT SUCH ADDRESS IN

OFFER

18.b. SUBMIT INVOICES TO ADDRESS SHOWN IN BLOCK 18a UNLESS BLOCK

BELOW IS CHECKED SEE ADDENDUM

19.

ITEM NO.

20.

SCHEDULE OF SUPPLIES / SERVICES

21.

QUANTITY

22.

UNIT

23.

UNIT PRICE

24.

AMOUNT

See Price Schedule

(Use Reverse and/or Attach Additional Sheets as Necessary)

25. ACCOUNTING AND APPROPRIATION DATA

26. TOTAL AWARD AMOUNT (For Govt. Use Only)

27a. SOLICITATION INCORPORATES BY REFERENCE FAR 52.212-1, 52.212-4. FAR 52.212-3 AND 52.212-5 ARE ATTACHED. ADDENDA ARE ARE NOT, ATTACHED.

27b. CONTRACT/PURCHASE ORDER INCORPORATES BY REFERENCE FAR 52.212-4. FAR 52.212-5 IS ATTACHED. ADDENDA ARE ARE NOT, ATTACHED.

28. CONTRACTOR IS REQUIRED TO SIGN THIS DOCUMENT AND RETURN COPIES TO

ISSUING OFFICE. CONTRACTOR AGREES TO FURNISH AND DELIVER ALL ITEMS SET FORTH

OR OTHERWISE IDENTIFIED ABOVE AND ON ANY ADDITIONAL SHEETS SUBJECT TO THE

TERMS AND CONDITIONS SPECIFIED HEREIN.

29. AWARD OF CONTRACT: REFERENCE OFFER DATED .

YOUR OFFER ON SOLICITATION (BLOCK 5), INCLUDING ANY ADDITIONS

OR CHANGES WHICH ARE SET FORTH HEREIN, IS ACCEPTED AS TO

ITEMS:

30a. SIGNATURE OF OFFEROR/CONTRACTOR 31a. UNITED STATES OF AMERICA (SIGNATURE OF CONTRACTING OFFICER)

30b. NAME AND TITLE OF SIGNER (TYPE OR PRINT)

30c. DATE SIGNED

31b. NAME OF CONTRACTING OFFICER (TYPE OR PRINT)

Jerry L. Black, Contracting Officer CO-05-017

31c. DATE SIGNED

AUTHORIZED FOR LOCAL REPRODUCTION STANDARD FORM 1449 (03/2005)

Computer Generated OMB No. 0990-0115 Prescribed by GSA - FAR (48 CFR) 53.212

OMB NO. 0990-0115

19.

ITEM NO.

20.

SCHEDULE OF SUPPLIES / SERVICES

21.

QUANTITY

22.

UNIT

23.

UNIT PRICE

24.

UNIT PRICE

SEE PRICE SCHEDULE

32a. QUANTITY IN COLUMN 21 HAS BEEN

RECEIVED INSPECTED ACCEPTED, AND CONFORMS TO THE CONTRACT, EXCEPT AS NOTED:

32b. SIGNATURE OF AUTHORIZED GOVERNMENT

REPRESENTATIVE

32c. DATE

32d. PRINTED NAME AND TITLE OF AUTHORIZED GOVERNMENT

REPRESENTATIVE

32e. MAILING ADDRESS OF AUTHORIZED GOVERNMENT REPRESENTATIVE

32f. TELEPHONE NUMBER OF AUTHORIZED GOVERNMENT REPRESENTATIVE

32.g E-MAIL OF AUTHORIZED GOVERNMENT REPRESENTATIVE

33. SHIP NUMBER 34. VOUCHER NUMBER

35. AMOUNT VERIFIED

CORRECT FOR

36. PAYMENT

COMPLETE PARTIAL FINAL

37. CHECK NUMBER

PARTIAL FINAL

38. S/R ACCOUNT NO.

39. S/R VOUCHER NUMBER

40. PAID BY

41.a I CERTIFY THIS ACCOUNT IS CORRECT AND PROPER FOR PAYMENT 42a. RECEIVED BY (Print)

41b. SIGNATURE AND TITLE OF CERTIFYING OFFICICER

41c. DATE

42b. RECEIVED AT (Location)

42c. DATE REC’D (YY/MM/DD)

42d. TOTAL CONTAINERS

STANDARD FORM 1449 (REV 3/2005) BACK