SF_1449-Mobile_CT_at_CRSU.doc

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

10-18-021-KN

6. SOLICITATION ISSUE DATE

Kenny Nicholson, Contract Specialist

b. TELEPHONE NUMBER (No collect calls)

(406) 247-7071

8. OFFER DUE DATE / LOCAL TIME

3/23/18 at 5pm MST

10. THIS ACQUISITION IS

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UNRESTRICTED OR

NAICS: 621512

SIZE STANDARD: $15.00 Million

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SET ASIDE: 100 % FOR

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SMALL BUSINESS

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HUBZONE SMALL BUSINESS

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EMERGING SMALL BUSINESS

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8(A)

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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

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SEE SCHEDULE

12. DISCOUNT TERMS

IHS NET 30P

13a.

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THIS CONTRACT IS A RATED ORDER UNDER DPAS (15 CFR 700)

13b. RATING

14. METHOD OF SOLICITATION

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RFQ FORMCHECKBOX

IFB FORMCHECKBOX

RFP

FACILITY

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

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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 FORMCHECKBOX

SEE ADDENDUM

19.

ITEM NO.

20.

SCHEDULE OF SUPPLIES / SERVICES

21.

QUANTITY

22.

UNIT

23.

UNIT PRICE

24.

AMOUNT

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

25. ACCOUNTING AND APPROPRIATION DATA

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

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27a. SOLICITATION INCORPORATES BY REFERENCE FAR 52.212-1, 52.212-4. FAR 52.212-3 AND 52.212-5 ARE ATTACHED. ADDENDA FORMCHECKBOX

ARE FORMCHECKBOX

ARE NOT, ATTACHED.

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27b. CONTRACT/PURCHASE ORDER INCORPORATES BY REFERENCE FAR 52.212-4. FAR 52.212-5 IS ATTACHED. ADDENDA FORMCHECKBOX

ARE FORMCHECKBOX

ARE NOT, ATTACHED.

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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.

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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:

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

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

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RECEIVED FORMCHECKBOX

INSPECTED FORMCHECKBOX

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

35. AMOUNT VERIFIED CORRECT FOR

36. PAYMENT

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COMPLETE FORMCHECKBOX

PARTIAL FORMCHECKBOX

FINAL

37. CHECK NUMBER

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FINAL

38. S/R ACCOUNT NO.

39. S/R VOUCHER NUMBER

40. PAID BY

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