Solicitation Amendment W91QVN25QA0040001 SF 30.pdf

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Medical Evacuation Services
Solicitation number
W91QVN25QA004-0001
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This is Amendment 0001 to solicitation W91QVN25QA004 for medical evacuation services issued by the Army Contracting Command. The amendment extends the response due date from December 30, 2024 to January 3, 2025 and modifies the period of performance from January 2-5, 2025 to January 6-16, 2025.

The services require the contractor to provide air ambulance transport with critical care capabilities to transfer a non-ambulatory patient and non-medical attendant from St. Mary's Hospital in Pyeongtaek, South Korea to University of California San Francisco Medical Center. Key requirements include continuous ECG monitoring, advanced life support, and critical care transport teams consisting of at least two medical attendants (RN/RN, RN/PA, RN/MD, or RN/EMT-P). The contractor must be CAMTS accredited, CARB certified, and have passed FAA inspections with no groundings in the past year. Required insurance includes $30 million in aircraft liability and $5 million in professional liability coverage.

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11. THIS ITEM ONLY APPLIES TO AMENDMENTS OF SOLICITATIONS

The above numbered solicitation is amended as set forth in Item 14. The hour and date specified for receipt of Offers is extended. is not extended.

Offers must acknowledge receipt of this amendment prior to the hour and date specified in the solicitation or as amended, by one of the following methods:

(a) By completing items 8 and 15, and returning copies of the amendment; (b) By acknowledging receipt of this amendment on each copy of the offer submitted;

or (c) By separate letter or electronic communication which includes a reference to the solicitation and amendment numbers. FAILURE OF YOUR ACKNOWLEDGMENT TO BE RECEIVED AT THE PLACE DESIGNATED FOR THE RECEIPT OF OFFERS PRIOR TO THE HOUR AND DATE SPECIFIED MAY RESULT IN REJECTION OF YOUR OFFER. If by virtue of this amendment you desire to change an offer already submitted, such change may be made by letter or electronic communication, provided each letter or electronic communication makes reference to the solicitation and this amendment, and is received prior to the opening hour and date specified.

12. ACCOUNTING AND APPROPRIATION DATA (If required)

13. THIS ITEM APPLIES ONLY TO MODIFICATIONS OF CONTRACTS/ORDERS.

IT MODIFIES THE CONTRACT/ORDER NUMBER AS DESCRIBED IN ITEM 14.

CHECK ONE A. THIS CHANGE ORDER IS ISSUED PURSUANT TO: (Specify authority) THE CHANGES SET FORTH IN ITEM 14 ARE MADE IN THE CONTRACT ORDER

NUMBER IN ITEM 10A.

B. THE ABOVE NUMBERED CONTRACT/ORDER IS MODIFIED TO REFLECT THE ADMINISTRATIVE CHANGES (such as changes in paying office, appropriation data, etc.) SET FORTH IN ITEM 14, PURSUANT TO THE AUTHORITY OF FAR 43.103(b).

C. THIS SUPPLEMENTAL AGREEMENT IS ENTERED INTO PURSUANT TO AUTHORITY OF:

D. OTHER (Specify type of modification and authority)

E. IMPORTANT: Contractor is not is required to sign this document and return copies to the issuing office.

14. DESCRIPTION OF AMENDMENT/MODIFICATION (Organized by UCF section headings, including solicitation/contract subject matter where feasible.)

Except as provided herein, all terms and conditions of the document referenced in Item 9A or 10A, as heretofore changed, remains unchanged and in full force and effect.

15A. NAME AND TITLE OF SIGNER (Type or print) 16A. NAME AND TITLE OF CONTRACTING OFFICER (Type or print)

15B. CONTRACTOR/OFFEROR

(Signature of person authorized to sign)

15C. DATE SIGNED 16B. UNITED STATES OF AMERICA

(Signature of Contracting Officer)

16C. DATE SIGNED

Previous edition unusable STANDARD FORM 30 (REV. 11/2016) Prescribed by GSA FAR (48 CFR) 53.243

AMENDMENT OF SOLICITATION/MODIFICATION OF CONTRACT 1. CONTRACT ID CODE PAGE OF PAGES

2. AMENDMENT/MODIFICATION NUMBER 3. EFFECTIVE DATE 4. REQUISITION/PURCHASE REQUISITION NUMBER 5. PROJECT NUMBER (If applicable)

6. ISSUED BY CODE 7. ADMINISTERED BY (If other than Item 6) CODE

8. NAME AND ADDRESS OF CONTRACTOR (Number, street, county, State and ZIP Code) (X) 9A. AMENDMENT OF SOLICITATION NUMBER

9B. DATED (SEE ITEM 11)

10A. MODIFICATION OF CONTRACT/ORDER NUMBE

10B. DATED (SEE ITEM 13)

CODE FACILITY CODE

SF 30 BLOCK 14 CONTINUATION PAGE

SUMMARY OF CHANGES

Solicitation/Contract Form Continuation

The following changes have been made:

INFORMATION FROM TO

Response Due Date 30 Dec 2024 03 Jan 2025

Continuation of Deliveries or Performance

The delivery information for the following CLIN(s) / SLIN(s) / ELIN(s) were modified:

INFORMATION FROM TO

Period of Performance 02 Jan 2025 to 05 Jan 2025 06 Jan 2025 to 16 Jan 2025

Place of Performance - W90MKT - 0411 AQ HQ CONTRACTING SUP

INFORMATION FROM TO

Delivery Delivery Estimated By 02 Jan 2025. Delivery Estimated By 06 Jan 2025.

Contract Clauses

Additional Information/Notes

The following clauses were deleted:

FAR Clauses Incorporated by Reference

Number Title Effective Date Alternate/ Deviation

Variation Effective Date

52.204-13 System for Award Management Maintenance. Oct 2018 52.204-18 Commercial and Government Entity Code Maintenance. Aug 2020

52.212-4 Contract Terms and Conditions-Commercial Products and Commercial Services.

Nov 2023

DFARS Clauses Incorporated by Reference

Alternate/Variation

W91QVN25QA0040001

Number Title Effective DateDeviation Effective Date

252.203-7000 Requirements Relating to Compensation of Former DoD Officials.

Sep 2011

252.203-7002 Requirement to Inform Employees of Whistleblower Rights.

Dec 2022

252.204-7012 Safeguarding Covered Defense Information and Cyber Incident Reporting.

May 2024

252.204-7018 Prohibition on the Acquisition of Covered Defense Telecommunications Equipment or Services.

Jan 2023

252.204-7020NIST SP 800-171 DoD Assessment Requirements. Nov 2023

252.225-7056 Prohibition Regarding Business Operations with the Maduro Regime.

Jan 2023

252.232-7003 Electronic Submission of Payment Requests and Receiving Reports.

Dec 2018

252.232-7010Levies on Contract Payments. Dec 2006

252.244-7000 Subcontracts for Commercial Products or Commercial Services.

Nov 2023

DFARS Clauses Incorporated by Full Text

252.225-7043Antiterrorism/Force Protection for Defense Contractors Outside the United States.

(Jun 2015)

As prescribed in 225.372-2, use the following clause:

ANTITERRORISM/FORCE PROTECTION POLICY FOR DEFENSE CONTRACTORS OUTSIDE

THE UNITED STATES (JUN 2015)

(a) . " United States ," as used in this clause, means, the 50 States, the District of Definition Columbia , and outlying areas.

(b) Except as provided in paragraph (c) of this clause, the Contractor and its subcontractors, if performing or traveling outside the United States under this contract, shall-

(1) Affiliate with the Overseas Security Advisory Council, if the Contractor or subcontractor is a U.S. entity;

(2) Ensure that Contractor and subcontractor personnel who are U.S. nationals and are in-country on a non-transitory basis, register with the U.S. Embassy, and that Contractor and subcontractor personnel who are third country nationals comply with any security related requirements of the Embassy of their nationality;

(3) Provide, to Contractor and subcontractor personnel, antiterrorism/force protection awareness information commensurate with that which the Department of Defense (DoD) provides to its military and civilian personnel and their families, to the extent such information can be made available prior to travel outside the United States; and

(4) Obtain and comply with the most current antiterrorism/force protection guidance for Contractor and subcontractor personnel.

(c) The requirements of this clause do not apply to any subcontractor that is -

(1) A foreign government;

(2) A representative of a foreign government; or

(3) A foreign corporation wholly owned by a foreign government.

(d) Information and guidance pertaining to DoD antiterrorism/force protection can be obtained from

(1) For Army contracts: HQDA-AT; telephone, DSN 222-9832 or commercial (703) 692-9832.

.(Contracting Officer to insert applicable information cited in PGI 225.372-1 (DFARS/PGI view))

(End of clause)

252.232-7006Wide Area WorkFlow Payment Instructions. (Jan 2023)

As prescribed in 232.7004(b), use the following clause:

WIDE AREA WORKFLOW PAYMENT INSTRUCTIONS (JAN 2023)

(a) As used in this clause- Definitions.

"Department of Defense Activity Address Code (DoDAAC)" is a six position code that uniquely identifies a unit, activity, or organization.

"Document type" means the type of payment request or receiving report available for creation in Wide Area WorkFlow (WAWF).

"Local processing office (LPO)" is the office responsible for payment certification when payment certification is done external to the entitlement system.

"Payment request" and "receiving report" are defined in the clause at 252.232-7003, Electronic Submission of Payment Requests and Receiving Reports.

(b) The WAWF system provides the method to electronically process vendor Electronic invoicing.

payment requests and receiving reports, as authorized by Defense Federal Acquisition Regulation Supplement (DFARS) 252.232-7003, Electronic Submission of Payment Requests and Receiving Reports.

(c) To access WAWF, the Contractor shall- WAWF access.

(1) Have a designated electronic business point of contact in the System for Award Management at https://www.sam.gov; and

(2) Be registered to use WAWF at https://wawf.eb.mil/ following the step-by-step procedures for self-registration available at this web site.

(d) The Contractor should follow the training instructions of the WAWF Web- WAWF training.

Based Training Course and use the Practice Training Site before submitting payment requests through WAWF. Both can be accessed by selecting the "Web Based Training" link on the WAWF home page at https://wawf.eb.mil/

(e) Document submissions may be via web entry, WAWF methods of document submission.

Electronic Data Interchange, or File Transfer Protocol.

(f) The Contractor shall use the following information when WAWF payment instructions.

submitting payment requests and receiving reports in WAWF for this contract or task or delivery order:

(1) The Contractor shall submit payment requests using the following Document type.

document type(s):

(i) For cost-type line items, including labor-hour or time-and-materials, submit a cost voucher.

(ii) For fixed price line items-

(A) That require shipment of a deliverable, submit the invoice and receiving report specified by the Contracting Officer.

(Contracting Officer: Insert applicable invoice and receiving report document type(s) for fixed price line items that require shipment of a deliverable.)

(B) For services that do not require shipment of a deliverable, submit either the Invoice 2in1, which meets the requirements for the invoice and receiving report, or the applicable invoice and receiving report, as specified by the Contracting Officer.

(Contracting Officer: Insert either "Invoice 2in1" or the applicable invoice and receiving report document type(s) for fixed price line items for services.)

(iii) For customary progress payments based on costs incurred, submit a progress payment request.

(iv) For performance based payments, submit a performance based payment request.

(v) For commercial financing, submit a commercial financing request.

(2) ) Fast Pay requests are only permitted when Federal Acquisition Regulation (FAR) 52.213-1 is included in the contract.

[Note: The Contractor may use a WAWF "combo" document type to create some combinations of invoice and receiving report in one step.]

(3) The Contractor shall use the information in the Routing Data Table Document routing.

below only to fill in applicable fields in WAWF when creating payment requests and receiving reports in the system.

Routing Data Table*

Field Name in WAWF Data to be entered in WAWF

Pay Official DoDAAC W56GBU

Issue By DoDAAC W91QVN

Admin DoDAAC W91QVN

Inspect By DoDAAC W91QVN

Ship To Code W91QVN

Ship From Code ____

Mark For Code ____

Service Approver (DoDAAC) ____

Service Acceptor (DoDAAC) ____

Accept at Other DoDAAC ____

LPO DoDAAC ____

DCAA Auditor DoDAAC ____

Other DoDAAC(s) ____

(*Contracting Officer: Insert applicable DoDAAC information. If multiple ship to/acceptance locations apply, insert "See Schedule" or "Not applicable.")

(**Contracting Officer: If the contract provides for progress payments or performance-based payments, insert the DoDAAC for the contract administration office assigned the functions under FAR 42.302(a) (13).)

(4) The Contractor shall ensure a payment request includes documentation Payment request.

appropriate to the type of payment request in accordance with the payment clause, contract financing clause, or Federal Acquisition Regulation 52.216-7, Allowable Cost and Payment, as applicable.

(5) The Contractor shall ensure a receiving report meets the requirements of Receiving report.

DFARS Appendix F.

(g) WAWF point of contact.

(1) The Contractor may obtain clarification regarding invoicing in WAWF from the following contracting activity's WAWF point of contact.

(Contracting Officer: Insert applicable information or "Not applicable.")

(2) Contact the WAWF helpdesk at 866-618-5988, if assistance is needed.

(End of clause)

Contract Terms and Conditions Required To Implement Statutes or Executive Orders — Commercial Products and Commercial Services

Additional Information/Notes

The following clauses were modified:

52.212-5Contract Terms and Conditions Required To Implement Statutes or Executive Orders- Commercial Products and Commercial Services.Nov 2024 hereby reads as follows:

As prescribed in , insert the following clause: 12.301(b)(4)

Contract Terms and Conditions Required To Implement Statutes or Executive Orders-Commercial Products and Commercial Services (Nov 2024)

(a) The Contractor shall comply with the following Federal Acquisition Regulation (FAR) clauses, which are incorporated in this contract by reference, to implement provisions of law or Executive orders applicable to acquisitions of commercial products and commercial services:

(1) 52.203-19, Prohibition on Requiring Certain Internal Confidentiality Agreements or Statements (Jan (section 743 of Division E, Title VII, of the Consolidated and Further Continuing Appropriations 2017)

Act, 2015 (Pub. L. 113-235) and its successor provisions in subsequent appropriations acts (and as extended in continuing resolutions)).

(2) 52.204-23, Prohibition on Contracting for Hardware, Software, and Services Developed or Provided by Kaspersky Lab Covered Entities (Section 1634 of Pub. L. 115-91).(Dec 2023)

(3) 52.204-25, Prohibition on Contracting for Certain Telecommunications and Video Surveillance Services or Equipment. (Section 889(a)(1)(A) of Pub. L. 115-232).(Nov 2021)

(4) 52.209-10, Prohibition on Contracting with Inverted Domestic Corporations .(Nov 2015)

(5) 52.232-40, Providing Accelerated Payments to Small Business Subcontractors (31 U.S.C. (Mar 2023) 3903 and 10 U.S.C. 3801).

(6) 52.233-3, Protest After Award (31 U.S.C. 3553).(Aug 1996)

(7) 52.233-4, Applicable Law for Breach of Contract Claim (Public Laws 108-77 and 108-(Oct 2004) 78 ( 19 U.S.C. 3805 note)).

(b) The Contractor shall comply with the FAR clauses in this paragraph (b) that the Contracting Officer has indicated as being incorporated in this contract by reference to implement provisions of law or Executive orders applicable to acquisitions of commercial products and commercial services:

[ .]Contracting Officer check as appropriate

52.203-6, Restrictions on Subcontractor Sales to the Government with (1) (Jun 2020), Alternate I (Nov (41 U.S.C. 4704 and 10 U.S.C. 4655). 2021)

52.203-13, Contractor Code of Business Ethics and Conduct (41 U.S.C. 3509)).(2) (Nov 2021)

52.203-15, Whistleblower Protections under the American Recovery and Reinvestment Act of (3) 2009 (Section 1553 of Pub. L. 111-5). (Applies to contracts funded by the American (Jun 2010) Recovery and Reinvestment Act of 2009.)

52.203-17, Contractor Employee Whistleblower Rights (41 U.S.C. 4712); this clause (4) (Nov 2023) does not apply to contracts of DoD, NASA, the Coast Guard, or applicable elements of the intelligence community-see FAR 3.900(a).

52.204-10, Reporting Executive Compensation and First-Tier Subcontract Awards (5) (Jun 2020) (Pub. L. 109-282) ( 31 U.S.C. 6101 note).

[Reserved].(6)

52.204-14, Service Contract Reporting Requirements (Pub. L. 111-117, section 743 of (7) (Oct 2016) Div. C).

52.204-15, Service Contract Reporting Requirements for Indefinite-Delivery Contracts (8) (Oct 2016) (Pub. L. 111-117, section 743 of Div. C).

52.204-27, Prohibition on a ByteDance Covered Application (Section 102 of Division (9) (Jun 2023) R of Pub. L. 117-328).

52.204-28, Federal Acquisition Supply Chain Security Act Orders-Federal Supply Schedules, (10) Governmentwide Acquisition Contracts, and Multi-Agency Contracts. (Pub. L. 115-390, title (Dec 2023)

II).

(11)

(i) 52.204-30, Federal Acquisition Supply Chain Security Act Orders-Prohibition. (Pub. L. (Dec 2023) 115-390, title II).

Alternate I of 52.204-30.(ii) (Dec 2023)

52.209-6, Protecting the Government's Interest When Subcontracting with Contractors Debarred, (12) Suspended, or Proposed for Debarment. (31 U.S.C. 6101 note).(Nov 2021)

52.209-9, Updates of Publicly Available Information Regarding Responsibility Matters (13) (Oct (41 U.S.C. 2313).2018)

[Reserved].(14)

52.219-3, Notice of HUBZone Set-Aside or Sole-Source Award ( ) (15 U.S.C. 657a).(15) Oct 2022

52.219-4, Notice of Price Evaluation Preference for HUBZone Small Business Concerns ((16) Oct ) (if the offeror elects to waive the preference, it shall so indicate in its offer) (15 U.S.C. 657a).2022

[Reserved](17)

(18)

(i) 52.219-6, Notice of Total Small Business Set-Aside (15 U.S.C. 644).(Nov 2020)

Alternate I of 52.219-6.(ii) (Mar 2020)

(19)

(i) 52.219-7, Notice of Partial Small Business Set-Aside (15 U.S.C. 644).(Nov 2020)

Alternate I of 52.219-7.(ii) (Mar 2020)

52.219-8, Utilization of Small Business Concerns ( ) (15 U.S.C. 637(d)(2) and (3)).(20) Feb 2024

(21)

(i) 52.219-9, Small Business Subcontracting Plan ( ) (15 U.S.C. 637(d)(4)).Sep 2023

Alternate I of 52.219-9.(ii) (Nov 2016)

Alternate II of 52.219-9.(iii) (Nov 2016)

Alternate III of 52.219-9.(iv) (Jun 2020)

Alternate IV ( ) of 52.219-9.(v) Sep 2023

(22)

(i) 52.219-13, Notice of Set-Aside of Orders (15 U.S.C. 644(r)).(Mar 2020)

Alternate I of 52.219-13.(ii) (Mar 2020)

52.219-14, Limitations on Subcontracting ( ) (15 U.S.C. 657s).(23) Oct 2022

52.219-16, Liquidated Damages-Subcontracting Plan (15 U.S.C. 637(d)(4)(F)(i)).(24) (Sep 2021)

52.219-27, Notice of Set-Aside for, or Sole-Source Award to, Service-Disabled Veteran-Owned (25) Small Business (SDVOSB) Concerns Eligible Under the SDVOSB Program ( ) (15 U.S.C. 657f).Feb 2024

(26)

(i) 52.219-28, Post Award Small Business Program Rerepresentation ( ) (15 U.S.C. 632(a)(2)).Feb 2024

Alternate I of 52.219-28.(ii) (Mar 2020)

52.219-29, Notice of Set-Aside for, or Sole-Source Award to, Economically Disadvantaged (27) Women-Owned Small Business Concerns ( ) (15 U.S.C. 637(m)).Oct 2022

52.219-30, Notice of Set-Aside for, or Sole-Source Award to, Women-Owned Small Business (28) Concerns Eligible Under the Women-Owned Small Business Program ( ) (15 U.S.C. 637(m)).Oct 2022

52.219-32, Orders Issued Directly Under Small Business Reserves (15 U.S.C. 644(r)).(29) (Mar 2020)

52.219-33, Nonmanufacturer Rule (15 U.S.C. 637(a)(17)).(30) (Sep 2021)

52.222-3, Convict Labor (E.O.11755).(31) (Jun 2003)

52.222-19, Child Labor-Cooperation with Authorities and Remedies .(32) (Feb 2024)

52.222-21, Prohibition of Segregated Facilities .(33) (Apr 2015)

(34)

(i) 52.222-26, Equal Opportunity (E.O.11246).(Sep 2016)

Alternate I of 52.222-26.(ii) (Feb 1999)

(35)

(i) 52.222-35, Equal Opportunity for Veterans (38 U.S.C. 4212).(Jun 2020)

Alternate I of 52.222-35.(ii) (Jul 2014)

(36)

(i) 52.222-36, Equal Opportunity for Workers with Disabilities (29 U.S.C. 793).(Jun 2020)

Alternate I of 52.222-36.(ii) (Jul 2014)

52.222-37, Employment Reports on Veterans ( ) (38 U.S.C. 4212).(37) Jun 2020

52.222-40, Notification of Employee Rights Under the National Labor Relations Act (38) (Dec 2010) (E.O. 13496).

(39)

(i) 52.222-50, Combating Trafficking in Persons (22 U.S.C. chapter 78 and E.O. 13627).(Nov 2021)

Alternate I of 52.222-50 (22 U.S.C. chapter 78 and E.O. 13627).(ii) (Mar 2015)

52.222-54, Employment Eligibility Verification (Executive Order 12989). (Not (40) (May 2022) applicable to the acquisition of commercially available off-the-shelf items or certain other types of commercial products or commercial services as prescribed in FAR 22.1803.)

(41)

(i) 52.223-9, Estimate of Percentage of Recovered Material Content for EPA-Designated Items (May 2008) ( 42 U.S.C. 6962(c)(3)(A)(ii)). (Not applicable to the acquisition of commercially available off-the-shelf items.)

Alternate I of 52.223-9 (42 U.S.C. 6962(i)(2)(C)). (Not applicable to the acquisition of (ii) (May 2008) commercially available off-the-shelf items.)

52.223-11, Ozone-Depleting Substances and High Global Warming Potential Hydrofluorocarbons (42) (42 U.S.C. 7671, ).(May 2024) et seq.

52.223-12, Maintenance, Service, Repair, or Disposal of Refrigeration Equipment and Air (43) Conditioners (42 U.S.C. 7671, ).(May 2024) et seq.

52.223-20, Aerosols (42 U.S.C. 7671, ).(44) (May 2024) et seq.

52.223-21, Foams (42 U.S.C. 7671, ).(45) (May 2024) et seq.

52.223-23, Sustainable Products and Services (E.O. 14057, 7 U.S.C. 8102, 42 U.S.C. (46) (May 2024) 6962, 42 U.S.C. 8259b, and 42 U.S.C. 7671l).

(47)

(i) 52.224-3 Privacy Training (5 U.S.C. 552 a).(Jan 2017)

Alternate I of 52.224-3.(ii) (Jan 2017)

(48)

(i) 52.225-1, Buy American-Supplies (41 U.S.C. chapter 83).(Oct 2022)

Alternate I of 52.225-1.(ii) (Oct 2022)

(49)

(i) 52.225-3, Buy American-Free Trade Agreements-Israeli Trade Act (19 U.S.C. 3301 (NOV 2023) note, 19 U.S.C. 2112 note, 19 U.S.C. 3805 note, 19 U.S.C. 4001 note, 19 U.S.C. chapter 29 (sections 4501-4732), Public Law 103-182, 108-77, 108-78, 108-286, 108-302, 109-53, 109-169, 109-283, 110- 138, 112-41, 112-42, and 112-43.

Alternate I [Reserved].(ii)

Alternate II of 52.225-3.(iii) ( 2022)Dec

Alternate III of 52.225-3.(iv) (Feb 2024)

Alternate IV (Oct 2022) of 52.225-3.(v)

52.225-5, Trade Agreements (19 U.S.C. 2501, ., 19 U.S.C. 3301 note).(50) (NOV 2023) et seq

52.225-13, Restrictions on Certain Foreign Purchases (E.O.'s, proclamations, and (51) (Feb 2021) statutes administered by the Office of Foreign Assets Control of the Department of the Treasury).

52.225-26, Contractors Performing Private Security Functions Outside the United States (Oct (52) 2016) (Section 862, as amended, of the National Defense Authorization Act for Fiscal Year 2008; 10 U.S.

C. Subtitle A, Part V, Subpart G Note).

52.226-4, Notice of Disaster or Emergency Area Set-Aside (Nov 2007) (42 U.S.C. 5150).(53)

52.226-5, Restrictions on Subcontracting Outside Disaster or Emergency Area (42 U.(54) (Nov 2007) S.C. 5150).

52.226-8, Encouraging Contractor Policies to Ban Text Messaging While Driving (E.(55) (May 2024) O. 13513).

52.229-12, Tax on Certain Foreign Procurements .(56) (Feb 2021)

52.232-29, Terms for Financing of Purchases of Commercial Products and Commercial Services (57) (41 U.S.C. 4505, 10 U.S.C. 3805).(Nov 2021)

52.232-30, Installment Payments for Commercial Products and Commercial Services (58) (Nov 2021) (41 U.S.C. 4505, 10 U.S.C. 3805).

52.232-33, Payment by Electronic Funds Transfer-System for Award Management (59) (Oct2018) (31 U.S.C. 3332).

52.232-34, Payment by Electronic Funds Transfer-Other than System for Award Management (60) (Jul 2013) (31 U.S.C. 3332).

52.232-36, Payment by Third Party (31 U.S.C. 3332).(61) (May 2014)

52.239-1, Privacy or Security Safeguards (5 U.S.C. 552a).(62) (Aug 1996)

(63) 52.240-1, Prohibition on Unmanned Aircraft Systems Manufactured or Assembled by American Security Drone Act-Covered Foreign Entities (Sections 1821-1826, Pub. L. 118-31, 41 U.S.(Nov 2024) C. 3901 note prec.).

52.242-5, Payments to Small Business Subcontractors (15 U.S.C. 637(d)(13)).(64) (Jan 2017)

(65)

(i) 52.247-64, Preference for Privately Owned U.S.-Flag Commercial Vessels (46 U.S.C. (Nov 2021) 55305 and 10 U.S.C. 2631).

Alternate I of 52.247-64.(ii) (Apr 2003)

Alternate II of 52.247-64.(iii) (Nov 2021)

(c) The Contractor shall comply with the FAR clauses in this paragraph (c), applicable to commercial services, that the Contracting Officer has indicated as being incorporated in this contract by reference to implement provisions of law or Executive orders applicable to acquisitions of commercial products and commercial services:

[ ]Contracting Officer check as appropriate.

52.222-41, Service Contract Labor Standards (41 U.S.C. chapter67).(1) (Aug 2018)

52.222-42, Statement of Equivalent Rates for Federal Hires (29 U.S.C. 206 and 41 U.(2) (May 2014) S.C. chapter 67).

52.222-43, Fair Labor Standards Act and Service Contract Labor Standards-Price Adjustment (3) (Multiple Year and Option Contracts) (29 U.S.C. 206 and 41 U.S.C. chapter 67).(Aug 2018)

52.222-44, Fair Labor Standards Act and Service Contract Labor Standards-Price Adjustment (4) (May 2014) ( 29U.S.C.206 and 41 U.S.C. chapter 67).

52.222-51, Exemption from Application of the Service Contract Labor Standards to Contracts for (5) Maintenance, Calibration, or Repair of Certain Equipment-Requirements (May 2014) (41 U.S.

C. chapter 67).

52.222-53, Exemption from Application of the Service Contract Labor Standards to Contracts for (6) Certain Services-Requirements (41 U.S.C. chapter 67).(May 2014)

52.222-55, Minimum Wages for Contractor Workers Under Executive Order 14026 .(7) (Jan 2022)

52.222-62, Paid Sick Leave Under Executive Order 13706 (E.O. 13706).(8) (Jan 2022)

52.226-6, Promoting Excess Food Donation to Nonprofit Organizations (Jun 2020) (42 U.S.(9) C. 1792).

(d) . The Contractor shall comply with the provisions of this Comptroller General Examination of Record paragraph (d) if this contract was awarded using other than sealed bid, is in excess of the simplified acquisition threshold, as defined in FAR 2.101, on the date of award of this contract, and does not contain the clause at 52.215-2, Audit and Records-Negotiation.

(1) The Comptroller General of the United States, or an authorized representative of the Comptroller General, shall have access to and right to examine any of the Contractor's directly pertinent records involving transactions related to this contract.

(2) The Contractor shall make available at its offices at all reasonable times the records, materials, and other evidence for examination, audit, or reproduction, until 3 years after final payment under this contract or for any shorter period specified in FAR subpart 4.7, Contractor Records Retention, of the other clauses of this contract. If this contract is completely or partially terminated, the records relating to the work terminated shall be made available for 3 years after any resulting final termination settlement.

Records relating to appeals under the disputes clause or to litigation or the settlement of claims arising under or relating to this contract shall be made available until such appeals, litigation, or claims are finally resolved.

(3) As used in this clause, records include books, documents, accounting procedures and practices, and other data, regardless of type and regardless of form. This does not require the Contractor to create or maintain any record that the Contractor does not maintain in the ordinary course of business or pursuant to a provision of law.

(e)

(1) Notwithstanding the requirements of the clauses in paragraphs (a), (b), (c), and (d) of this clause, the Contractor is not required to flow down any FAR clause, other than those in this paragraph (e)(1), in a subcontract for commercial products or commercial services. Unless otherwise indicated below, the extent of the flow down shall be as required by the clause-

(i) 52.203-13, Contractor Code of Business Ethics and Conduct (41 U.S.C. 3509).(Nov 2021)

(ii) 52.203-17, Contractor Employee Whistleblower Rights (41 U.S.C. 4712).(Nov 2023)

(iii) 52.203-19, Prohibition on Requiring Certain Internal Confidentiality Agreements or Statements (Jan 2017) (section 743 of Division E, Title VII, of the Consolidated and Further Continuing Appropriations Act, 2015 (Pub. L. 113-235) and its successor provisions in subsequent appropriations acts (and as extended in continuing resolutions)).

(iv) 52.204-23, Prohibition on Contracting for Hardware, Software, and Services Developed or Provided by Kaspersky Lab Covered Entities (Section 1634 of Pub. L. 115-91).(Dec 2023)

(v) 52.204-25, Prohibition on Contracting for Certain Telecommunications and Video Surveillance Services or Equipment. (Section 889(a)(1)(A) of Pub. L. 115-232).(Nov 2021)

(vi) 52.204-27, Prohibition on a ByteDance Covered Application (Section 102 of Division R (Jun 2023) of Pub. L. 117-328).

(vii)

(A) 52.204-30, Federal Acquisition Supply Chain Security Act Orders-Prohibition. (Pub. L. (Dec 2023) 115-390, title II).

(B) Alternate I of 52.204-30.(Dec 2023)

(viii) 52.219-8, Utilization of Small Business Concerns ( ) (15 U.S.C. 637(d)(2) and (3)), in all Feb 2024 subcontracts that offer further subcontracting opportunities. If the subcontract (except subcontracts to small business concerns) exceeds the applicable threshold specified in FAR 19.702(a) on the date of subcontract award, the subcontractor must include 52.219-8 in lower tier subcontracts that offer subcontracting opportunities.

(ix) 52.222-21, Prohibition of Segregated Facilities .(Apr 2015)

(x) 52.222-26, Equal Opportunity (E.O.11246).(Sep 2015)

(xi) 52.222-35, Equal Opportunity for Veterans (38 U.S.C. 4212).(Jun 2020)

(xii) 52.222-36, Equal Opportunity for Workers with Disabilities (29 U.S.C. 793).(Jun 2020)

(xiii) 52.222-37, Employment Reports on Veterans (38 U.S.C. 4212).(Jun 2020)

(xiv) 52.222-40, Notification of Employee Rights Under the National Labor Relations Act (E.(Dec 2010) O. 13496). Flow down required in accordance with paragraph (f) of FAR clause 52.222-40.

(xv) 52.222-41, Service Contract Labor Standards (41 U.S.C. chapter 67).(Aug 2018)

(xvi)

(A) 52.222-50, Combating Trafficking in Persons (22 U.S.C. chapter 78 and E.O 13627).(Nov 2021)

(B) Alternate I of 52.222-50 (22 U.S.C. chapter 78 and E.O. 13627).(Mar 2015)

(xvii) 52.222-51, Exemption from Application of the Service Contract Labor Standards to Contracts for Maintenance, Calibration, or Repair of Certain Equipment-Requirements (May 2014) (41 U.S.

C. chapter 67).

(xviii) 52.222-53, Exemption from Application of the Service Contract Labor Standards to Contracts for Certain Services-Requirements (41 U.S.C. chapter 67).(May 2014)

(xix) 52.222-54, Employment Eligibility Verification (E.O. 12989).(May 2022)

(xx) 52.222-55, Minimum Wages for Contractor Workers Under Executive Order 14026 .(Jan 2022)

(xxi) 52.222-62, Paid Sick Leave Under Executive Order 13706 (E.O. 13706).(Jan 2022)

(xxii)

(A) 52.224-3, Privacy Training (Jan 2017) (5 U.S.C. 552a).

(B) Alternate I of 52.224-3.(Jan 2017)

(xxiii) 52.225-26, Contractors Performing Private Security Functions Outside the United States (Oct (Section 862, as amended, of the National Defense Authorization Act for Fiscal Year 2008; 10 U.S.2016)

C. Subtitle A, Part V, Subpart G Note).

(xxiv) 52.226-6, Promoting Excess Food Donation to Nonprofit Organizations (42 U.S.(Jun 2020) C. 1792). Flow down required in accordance with paragraph (e) of FAR clause 52.226-6.

(xxv) 52.232-40, Providing Accelerated Payments to Small Business Subcontractors (Mar 2023) (31 U.S.

C. 3903 and 10 U.S.C. 3801). Flow down required in accordance with paragraph (c) of 52.232-40.

(xxvi) 52.240-1, Prohibition on Unmanned Aircraft Systems Manufactured or Assembled by American Security Drone Act-Covered Foreign Entities (Sections 1821-1826, Pub. L. 118-31, 41 U.S.(Nov 2024) C. 3901 note prec.).

(xxvii) 52.247-64, Preference for Privately Owned U.S.-Flag Commercial Vessels (46 U.S.(Nov 2021) C. 55305 and 10 U.S.C. 2631). Flow down required in accordance with paragraph (d) of FAR clause 52.247-64.

(2) While not required, the Contractor may include in its subcontracts for commercial products and commercial services a minimal number of additional clauses necessary to satisfy its contractual obligations.

(End of clause)

Addendum to Contract Clauses

Contract Clauses

Additional Information/Notes

The following clauses were deleted:

FAR Clauses Incorporated by Reference

Number Title Effective Date Alternate/ Deviation

Variation Effective Date

52.209-10 Prohibition on Contracting with Inverted Domestic Corporations.

Nov 2015

DFARS Clauses Incorporated by Reference

Number Title Effective Date Alternate/ Deviation

Variation Effective Date

252.222-7002Compliance with Local Labor Laws (Overseas). Jun 1997 252.225-7041Correspondence in English. Jun 1997 252.232-7008Assignment of Claims (Overseas). Jun 1997 252.233-7001Choice of Law (Overseas). Jun 1997

252.237-7010 Prohibition on Interrogation of Detainees by Contractor Personnel.

Jan 2023

List of Contract Documents, Exhibits, or Attachments

Miscellaneous text in this section has been modified to:

SPECIAL NOTICE All sources may submit a proposal or quote as applicable. However, the Republic of Korea (ROK)-United States (U.S.) Status of Forces Agreement (SOFA), precludes the U.S. Government from granting Invited Contractor or Technical Representative Status to any offeror, for this requirement.

All sources submitting a proposal or quote, as applicable, including U.S. sources, must already have, or obtain the requisite business licenses directly from the ROK Government, and conduct business in accordance with all applicable ROK laws, including but not limited to, rules and policies regarding labor, taxation, and immigration. Any contractor not already doing business in Korea, must submit adequate verification in its initial proposal or quote- that it has the requisite business licenses directly from the ROK Government to perform the contract and the capacity to conduct business in accordance with all applicable ROK laws, including but not limited to, rules and policies regarding labor, taxation, and immigration. If an initial proposal does not fully demonstrate this authorization and capacity, it will not be further considered for award. Whether an offeror demonstrates this authorization and capacity shall be determined by the Contracting Officer.

PERFORMANCE WORK STATEMENT

Medical Evacuation Services

1. :General

This is a non-personal service(s) contract under which the personnel rendering the service(s) are not subject, either by the contract's terms or by the manner of its administration, to the supervision and control usually prevailing in relationships between the Government and its employees.

2.Description of Services/Introduction: The contractor shall provide all vehicles, personnel, medical attendants, management, supplies, equipment, and necessary reporting for the provision of air ambulance transport and medical evacuation services. The aircrew is expected to operate in compliance with all applicable requirements of the Federal Aviation Administrative (FAA) regulation in respect of its General Operation Manual for air operations. The pilot in command of the aircraft, being overall responsible for safe mission execution, retains the right not to fly due to unsafe weather conditions. This is a firm-fixed price service contract. The Contract employees providing these services are here after referred to as Contract Service Provider (CSP).

2.1 Performance shall be according to the requirements contained in this PWS and the Commission Accreditation of Medical Transport Services (CAMTS). The Contractor must be Commercial Airlift Review Board (CARB) certified, CAMTS accredited, and have passed FAA inspections on all equipment, and have not been grounded by the FAA within the last year prior to award of this contract.

The Contractor shall provide proof of FAA inspections for the last year to the Contracting Officer (KO), at time of offer, under this request for quote, prior to contract award.

2.2 :Non-Personal Services Contract Any resulting contract will be a commercial, nonpersonal services contract, as defined in Federal Acquisition Regulation (FAR) 37.101, under which the Contractor will perform as an independent Contractor. The Contractor shall indemnify the Government for any liability producing act or omission by the Contractor, its employees and agents occurring during contract performance. The Contractor shall maintain medical Professional liability insurance in the minimum amount of $1 million per incident and $3 million in the aggregate and provide proof of coverage to the KO within three (3) working days before contract start date.

The Contractor shall ensure that its subcontractors, if any, have medical Professional liability insurance in these amounts. Verification will be required at time of contract award.

2.3. The Contractor will provide a physician Medical Director (MD) who has oversight of the care rendered by the healthcare provider CSPs on this contract. The Contractor MD is responsible for providing medical oversight to the nurses and paramedics and regarding aspects of patient care including scope of practice, State of California Emergency Medical Services Program standards, quality assurance, and quality improvement. The inspection and acceptance point for all services rendered under this contract will be by the KO.

3.Background: The purpose of medical evacuation is to transfer a non-ambulatory patient and non-medical attendant from St. Mary's Hospital, Pyeongtaek, South Korea to University of California San Francisco Medical Center, United States. The patient is to be transported by critical care air transport with continuous ECG monitoring and other life support requirements. It is further understood that only a physician or registered nurse (RN) with critical care training and current advanced cardiac life support will be designated as the medical flight attendant in accordance with the standards of CAMTS for any critical care transport. Critical care air transports require an additional team member, for a minimum of two medical attendants, (for example but not limited to RN/RN, RN/Physician's Assistant, RN/MD. RN /EMT-P). All personnel shall be available for each transport within an agreed upon response time between the Contractor and KO.

4. : Scope The Contractor shall provide air ambulance transport with hospital finder services that has long term and larger acute care for a definitive prognostic evaluation required to treat the patient. The rehabilitative

Contractor shall provide Advanced Life Support, Basic Life Support, and Critical Care Support to the patient.

Patient medical history and hospital services information will be coordinated to the Point of Contact listed in Paragraph 15 of this PWS.

5. Objective: The objective of this contract is to support the utilization of air ambulance transport that provides care and access to the patient requiring critical care.

6. Estimated date January 06-16, 2025. Period of Performance:

7. : Place of Performance St. Mary's Hospital, Pyeongtaek, South Korea to University of California San Francisco Medical Center, United States of America

8. The Contractor shall ensure that all Contractor personnel providing services meet the following requirements:

Contractor personnel shall be able to read, write, and speak English fluently and enunciate with sufficient clarity to effectively communicate with patients and other providers.

Contractor personnel shall possess sufficient initiative, interpersonal relationship skills and social sensitivity such that the Contractor personnel can relate to a variety of patients from diverse backgrounds.

CSPs are required to meet Continuing Medical Education (CME) requirements as determined by the provider's State of licensure. The Government will not reimburse for these costs.

CSP shall have sufficient skills, knowledge, and experience to perform the specific tasks listed for their specialty.

Contractor and CSPs shall abide by all standards, rules, and procedures including requirements for licensure, credentialing, and quality assurance programs.

CSP shall be required to take and maintain in a status, any on-going training as required by regulation, command directive, state law and/or any other inspecting entity.

Contractor personnel shall not have been convicted of a felony.

9. Non-Disclosure Requirements: Performance under this contract may require the Contractor to access data and information proprietary to a Government Agency, another Government Contractor, or of such nature that its dissemination or use other than as specified in this PWS would be averse to the interests of the Government or others. The Contractor and Contractor personnel shall not divulge, or release data or information developed, or obtained underperformance of this PWS, except to authorized Government personnel or upon written approval of the KO. The Contractor shall not use, disclose, or reproduce proprietary data, which bears a restrictive legend, other than as specified in this PWS. All documentation showing individual names or other personal information shall be controlled and protected under the provisions of the Privacy Act of 1974, Public Law 93-579, 5 United States Code (U.S.C.)Section 552a.

10. Protection of Government and Contract Information: Per Public Use Notice of Limitations stated by Defense imagery Management operations Center and contained at www.dimoc.mil/resources/limitations/ , the Contractor shall not cite any information (e.g., contract information, pictures, locations, etc.) obtained through this contract on any hard copy or digital marketing tools to include its company website.

11. Confidentiality of Information: Unless otherwise specified, all financial, statistical, personnel, and/or technical data which are furnished, produced or otherwise available to the CSP during the performance of this contract are considered confidential business information and shall not be used for purposes other than performance of work under this contract. None of the above information shall be released by the Contractor or CSP without prior written consent of the COR or KO.

12. Indemnity and Liability: The Contractor shall indemnify the Government for any liability resulting from an act or omission by the Contractor, its employees, or agents, occurring during contract performance. The Government assumes no responsibility for negligent acts of the Contractor, its employees, or agents. Services rendered by the Contractor shall be rendered in the capacity of an independent Contractor. The Government will not be liable for malpractice allegation against CSP based upon performance of the contract. The Contractor shall be required to carry malpractice and other insurance at levels acceptable to the Government prior to commencement of services. In accordance with FAR 52.237-7, the Contractor will indemnify the Government for any liability producing act or omission by the Contractor. If the Contractor uses a subcontractor in the performance of the contract, the Contractor is required to ensure that it's subcontractor, for provision of healthcare services contain the requirement of FAR 52.237-7, including the maintenance of medical liability insurance.

12.1. If any suit or action is filed or any claim is made against the CSP, which occurred during work performed by the Contractor under this contract, the Contractor shall immediately notify the COR and KO and promptly furnish them copies of all pertinent papers received.

12.2. The Contractor and CSP shall cooperate with the Government, without further compensation, in the processing, review, settlement, or defense of the suit, action, or claim. The Contractor shall be solely liable for any liability producing act or omission and shall maintain medical malpractice liability insurance and flight insurance in the following amounts:

12.3 The Contractor shall maintain $30 million in Aircraft Liability Insurance.

12.4. The Contractor shall maintain $5 million in Professional Liability Insurance.

12.5. The Contractor shall ensure that all subcontractors have medical liability insurance and flight insurance in the same amounts. Proof of insurance shall be submitted prior to performance of services under this contract.

13. : The CSP shall comply with all installation safety regulations. Such regulations include, but Safety are not limited to general safety, fire prevention, and waste disposal. Copies of these regulations are on file at the base's safety office or may be obtained through the COR.

14. Safety Accident Prevention Plan: The Contractor shall prepare and provide an accident prevention plan utilizing safety policies, and best-practice industry safety standards to develop a comprehensive safety plan that addresses the medical and aviation requirements of this PWS.

15. Points of Contact:

Customer POC: Paul Luntumbuez (Lou-Tom-Wez)

COMM(Local): 0503-355-3334

Email: paul.m.luntumbuez.civ@army.mil

Hesuk Helen Baek, MD

Deputy Director for Host Nation Affairs

Hospitalist

Brian D. Allgood Army Community Hospital (BDAACH)

Camp Humphreys, South Korea

Cell:010-7358-1844

US:+82-10-7358-1844

DSN:315-737-1215

5152.204-4024 SECURITY OF EMPLOYEES

(a) The Contractor agrees (1) to submit immediately to the Contracting Officer a complete confidential report of any information which the Contractor may have concerning existing or threatened espionage, sabotage, or subversive activity; (2) to submit to the Contracting Officer, upon written request, any and all information which the Contractor may have concerning any of its employees engaged in any work at any plant, factory, or site at which work under this contract is being performed; and (3) to exclude from the plant, factory, site, or part thereof at which work under this contract is being performed any person or persons whom the Contracting Officer, in the interest of security, may designate in writing.

(b) In any case, should the continued employment of any such person furnished by the Contractor for work under this contract be determined by the Contracting Officer to be prejudicial to the security interests of the Government, that person shall be immediately removed or transferred from that particular work specified. The decision by the Contracting Officer that such person should not be employed on work being done under this contract will be final.

(c) The Contracting Officer shall consult with the Contractor before final action is taken. It is understood that the decision of the Contracting Officer pursuant to this clause applies only to work under the contract and does not otherwise relate to the employer-employee relationship between the Contractor and its workers. The cost of replacing any contractor employee under the provisions of this clause shall be at no additional cost to the Government.

5152.204-4032 REPRESENTATIONS AND CERTIFICATIONS

(a) SUBCONTRACTING:

If the offeror contemplates subcontracting, it must obtain prior written approval of subcontractor from the PCO or ACO, and list below:(1) the names and addresses of the subcontractor(s), (2) the type of subcontracting, and (3) the estimated price for each subcontract.

(b) AFFILIATED OFFERORS:

(1) Business concerns are affiliates of each other when, either directly or indirectly one concern controls , or has the power to control the other, or a third party controls or has the power to control both.

(2) Each offeror shall furnish, below, the following information:

(i) Whether the offeror has any affiliates;

(ii) The names and addresses of all affiliates of the offeror; and

(iii) The names and addresses of all persons and concerns exercising control or ownership of the offeror and any or all of its affiliates, and whether they are common officers, directors, stockholders holding controlling interest, or otherwise.

AFFILIATED CONCERNS : (Name, location and, in detail, controlling interest in each).

(c) PRINCIPAL OWNER(S) OR STOCKHOLDER(S):

Each offeror shall list below the name(s) and address(es)of the principal owner(s) or stockholder(s) of the company and percentage of ownership. If a major portion is publicly traded and/or otherwise widely distributed, state that, with the percentage so affected.

(d) STANDARDS OF CONDUCT CERTIFICATION:

This is to certify that, to the best of my knowledge and belief, except as described below, no representative of this firm who deals with US Government employees on any aspect of this procurement is a former US Government employee, to include former US military personnel. I understand that this certification is continuing in nature and places a duty on me and my firm to notify the Contracting Officer of any additional individual(s) who fit the above description prior to the individual's assuming duties.

(i) Name ______________________________________________

Former rank/grade ____________________________________

Last US Government position ___________________________

(ii) Name ______________________________________________

Former rank/grade ____________________________________

Last US Government position ___________________________

(iii) Name ______________________________________________

Formerrank/grade ____________________________________

Last USGovernment position ___________________________

Firm ____________________________________________________

Name _____________________________________________________

Signature __________________________________________________

Title _____________________________________________________

Date of Execution ____________________________________________

(e) TAXES:

(1) References:

(i) Contract clause entitled "FAR 52.229-06Taxes--Foreign Fixed-Price Contracts (Jan 1991)."

(ii) US-ROK Status of Forces Agreement (SOFA), Articles IX and XVI.

(iii) ROK Customs Law, Law No. 1976, promulgated on 29November 1967, as amended.

(iv) ROK Value Added Tax Law, Law No. 2934, promulgated on22 December 1976 (effective date 1 July 1977), as amended.

(v) ROK Special Excise Tax Law, Law No. 2935, promulgated on22 December 1976 (effective date 1 July 1977), as amended.

(2) Contractor shall state the types and estimated amount of taxes that would normally apply to suchtransactions but are excluded from this proposal.

(i) Customs Tax (except forROK MND-funded contracts or delivery orders):

Name Number Cost/Unit of Item of Units w/o Tax % of Tax Tax/Unit Tax Total

This item will be imported specifically for thiscontract? Yes _____ No _____

(ii) Special Excise Tax:

Name Number Cost/Unit of Item of Units w/o Tax % of Tax Tax/Unit Tax Total

Name of item manufacturer

(iii) Value Added Tax (VAT):

Input VAT on materials purchased for this contract. 10%_____

Input VAT on transportation leased/rented for thiscontract.10% _____

Input VAT on equipment leased/rented for this contract. 10%_____

Input VAT on services purchased for this contract. 10% _____

Output VAT on total contract amount. 10% _____

(iv) Special Excise (Petroleum) Tax:

No. of U/P

Liters w/oTax Tax/Unit Total Tax Amount

Regular Gasoline ________ (L) ________ w________ w_____________

Premium Gasoline ________ (L) ________ w________ w_____________

Diesel ________ (L) ________ w________ w_____________

Other ________ (L) ________ w________ w_____________

(v) Education Tax.

(3) Name of the oil company from which POL products will bepurchased:

Oil Company: _________________________________________ (Name only)

(4) I…

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