SF 1413 - Statement and Acknowledgment.pdf
PDF 687 KB Posted
- Solicitation number
- 70Z03026QCLEV0097
About this file
This is a Standard Form 1413 (Statement and Acknowledgment) template used in federal contracting to document subcontract awards under prime contracts. The form is prescribed by the General Services Administration and Federal Acquisition Regulation (48 CFR 53.222(e)) with OMB Control Number 9000-0066, expiring May 31, 2027.
The form consists of two primary sections. Part I requires the prime contractor to provide a statement documenting a subcontract award, including the prime contract number, subcontract number, award date, and identifying information for both the prime contractor and subcontractor (name and address). The prime contractor must indicate whether the prime contract contains the "Contract Work Hours and Safety Standards Act – Overtime Compensation" clause, identify the firm awarding the subcontract, provide a description of work to be performed, and specify the project and location. Part II requires the subcontractor to acknowledge that specified labor standards clauses from the prime contract are incorporated into the subcontract, including provisions related to contract work hours and safety standards, payroll records, wage rate requirements, apprentices and trainees, Copeland Act compliance, debarment, and eligibility certification. The form also includes a field for listing any intermediate subcontractors. Both the prime contractor representative and subcontractor representative must sign and date the document. The estimated time to complete the form is 0.05 hours.
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| File | Type | Posted |
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| Picture 04.jpeg | JPEG file | |
| Picture 01.jpeg | JPEG file | |
| Picture 02.jpeg | JPEG file | |
| Picture 03.jpeg | JPEG file | |
| RFQ 70Z03026QCLEV0097.docx | DOCX document | |
| 70Z03026QCLEV0097 - SF 1442.pdf | ||
| Reference Information Sheet.pdf | ||
| 70Z03026QCLEV0097 - Statement of Work (August 2026).pdf | ||
| Request for Information (RFI).pdf | ||
| Wage Determinations - Lorain County OH.txt | TXT text file |
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Text version
Statement And Acknowledgment OMB Control Number: 9000-0066 Expiration Date: 5/31/2027
Part I - Statement Of Prime Contractor
1. Prime Contract Number 2. Date Subcontract
Awarded
3. Subcontract Number
Authorized For Local Reproduction Previous Edition Is Not Usable
STANDARD FORM 1413 (REV. 10/2023)
Prescribed by GSA/FAR (48 CFR) 53.222(e)
4. Prime Contractor 5. Subcontractor
a. Name a. Name
b. Street Address b. Street Address
c. City d. State e. ZIP Code c. City d. State e. ZIP Code
6. The prime contract does, does not contain the clause entitled "Contract Work Hours and Safety Standards Act -- Overtime Compensation."
7. The prime contractor states that under the contract shown in Item 1, a subcontract was awarded on the date shown in Item 2 to the subcontractor identified in Item 5 by the following firm:
a. Name Of Awarding Firm
b. Description Of Work By Subcontractor
8. Project 9. Location
10a. Name Of Person Signing 11. By (Signature) 12. Date Signed
10b. Title Of Person Signing
Part II - Acknowledgment Of Subcontractor
13. The subcontractor acknowledges that the following clauses of the contract shown in Item 1 are included in this subcontract:
Contract Work Hours and Safety Standards Act - Overtime Compensation (If included in prime contract see Block 6) Payrolls and Basic Records Withholding of Funds Disputes Concerning Labor Standards Compliance with Construction Wage Rate Requirements and Related Regulations
Construction Wage Rate Requirements Apprentices and Trainees Compliance with Copeland Act Requirements Subcontracts (Labor Standards) Contract Termination - Debarment Certification of Eligibility
Paperwork Reduction Act Statement - This information collection meets the requirements of 44 U.S.C. §
3507, as amended by section 2 of the Paperwork Reduction Act of 1995. You do not need to answer these questions unless we display a valid Office of Management and Budget (OMB) control number.
The OMB control number for this collection is 9000-0066. We estimate that it will take .05 hours to read the instructions, gather the facts, and answer the questions. Send only comments relating to our time estimate, including suggestions for reducing this burden, or any other aspects of this collection of information to: U.S. General Services Administration, Regulatory Secretariat Division (M1V1CB), 1800
F Street, NW, Washington, DC 20405.
15b. Title Of Person Signing
15a. Name Of Person Signing 16. By (Signature) 17. Date Signed
14. Name(s) Of Any Intermediate Subcontractors, If Any
A C
DB
STANDARD FORM 1413 (REV. 10/2023) BACK
1.6 Presentation Agent PDFlib 3.02 (C++/Win32) D:20050617125503-04'00' D:20080212101247-05'00' Presentation Agent Standard Form 1413 - Statement and Acknowledgment Statement And Acknowledgment OMB Control Number: 9000-0066 Expiration Date: 5/31/2027 Part I - Statement Of Prime Contractor
1. Prime Contract Number
2. Date Subcontract Awarded
3. Subcontract Number Authorized For Local Reproduction Previous Edition Is Not Usable
STANDARD FORM 1413 (REV. 10/2023)
Prescribed by GSA/FAR (48 CFR) 53.222(e)
4. Prime Contractor
5. Subcontractor
a. Name
a. Name
b. Street Address
b. Street Address
c. City
d. State
e. ZIP Code
c. City
d. State
e. ZIP Code
6. The prime contract does, does not contain the clause entitled "Contract Work Hours and Safety Standards Act -- Overtime Compensation."
7. The prime contractor states that under the contract shown in Item 1, a subcontract was awarded on the date shown in Item 2 to the subcontractor identified in Item 5 by the following firm:
a. Name Of Awarding Firm
b. Description Of Work By Subcontractor
8. Project
9. Location 10a. Name Of Person Signing
11. By (Signature)
12. Date Signed 10b. Title Of Person Signing Part II - Acknowledgment Of Subcontractor
13. The subcontractor acknowledges that the following clauses of the contract shown in Item 1 are included in this subcontract:
Contract Work Hours and Safety Standards Act - Overtime Compensation (If included in prime contract see Block 6) Payrolls and Basic Records Withholding of Funds Disputes Concerning Labor Standards Compliance with Construction Wage Rate Requirements and Related Regulations Construction Wage Rate Requirements Apprentices and Trainees Compliance with Copeland Act Requirements Subcontracts (Labor Standards) Contract Termination - Debarment Certification of Eligibility Paperwork Reduction Act Statement - This information collection meets the requirements of 44 U.S.C. § 3507, as amended by section 2 of the Paperwork Reduction Act of 1995. You do not need to answer these questions unless we display a valid Office of Management and Budget (OMB) control number. The OMB control number for this collection is 9000-0066. We estimate that it will take .05 hours to read the instructions, gather the facts, and answer the questions. Send only comments relating to our time estimate, including suggestions for reducing this burden, or any other aspects of this collection of information to: U.S. General Services Administration, Regulatory Secretariat Division (M1V1CB), 1800 F Street, NW, Washington, DC 20405.
15b. Title Of Person Signing 15a. Name Of Person Signing
16. By (Signature)
17. Date Signed
14. Name(s) Of Any Intermediate Subcontractors, If Any A C D B
STANDARD FORM 1413 (REV. 10/2023) BACK
| 1. Enter the Prime Contract Number. : |
| 4a. Enter the Prime Contractor's Name. : |
| 4b. Enter the Prime Contractor's Street Address. : |
| 4c. Enter the Prime Contractor's City.: |
| 7a. Enter the Name of the Awarding Firm.: |
| 10a. Enter the Name of the Person signing this form as the Prime Contractor. : |
| 10b. Enter the Title of the Person signing this form as the Prime Contractor. : |
| 8. Enter the Project name.: |
| 9. Enter the Location. : |
| 7b. Enter a Description of Work completed by the Subcontractor. : |
| 5c. Enter the Subcontractor's City.: |
| 4e. Enter the Prime Contractor's Zone Improvement Plan (ZIP) Code. : |
| 5e. Enter the Subcontractor's Zone Improvement Plan (ZIP) Code. : |
| 4d. Enter the Prime Contractor's State.: |
| 5d. Enter the Subcontractor's State.: |
| 3. Enter the Subcontract Number. : |
| 5a. Enter the Subcontractor's Name.: |
| 5b. Enter the Subcontractor's Street Address.: |
| 2. Enter the Date the Subcontract was Awarded (enter 2 digit month, 2 digit day and 4 digit year).: |
| 12. If you are the Prime Contractor, enter the Date you signed this form (enter 2 digit month, 2 digit day and 4 digit year).: |
| 6. Click here to select, "the prime contract does contain the clause entitled "Contract Work Hours and Safety Standards Act -- Overtime Compensation.": 0 |
| 6. Click here to select, "the prime contract does NOT contain the clause entitled "Contract Work Hours and Safety Standards Act -- Overtime Compensation.": 0 |
| 16. Sign here if you are the Subcontractor.: |
| 15b. Enter the Title of the Person Signing this form as the Subcontractor. : |
| 15a. Enter the Name of the Person Signing this form as the Subcontractor. : |
| 17. If you are the Subcontractor, enter the Date you signed this form (enter 2 digit month, 2 digit day and 4 digit year).: |
| 14a. Enter the First Name of an Intermediate Subcontractor, If Any. : |
| 14c. Enter the Third Name of an Intermediate Subcontractor, If Any.: |
| 14d. Enter the Fourth Name of an Intermediate Subcontractor, If Any.: |
| 14b. Enter the Second Name of an Intermediate Subcontractor, If Any.: |
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