Attachment_1_-_DD_Form_1155_(Example).pdf
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- Solicitation number
- SP4520-14-R-0003
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Attachment 1 - DD Form 1155 (Example)
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ORDER FOR SUPPLIES OR SERVICES
1. CONTRACT/PURCH ORDER/AGREEMENT NO. 2. DELIVERY ORDER/CALL NO. 4. REQUISITION/PURCH REQUEST NO.3. DATE OF ORDER/CALL
(YYYYMMMDD)
5. PRIORITY
6. ISSUED BY 7. ADMINISTERED BY If other than 6 8. DELIVERY FOB
9. CONTRACTOR
NAME
AND
ADDRESS
10. DELIVER TO FOB POINT BY (Date)
(YYYYMMMDD)
12. DISCOUNT TERMS
13. MAIL INVOICES TO THE ADDRESS IN BLOCK
(See Schedule if other)
11. X IF BUSINESS IS
14. SHIP TO 15. PAYMENT WILL BE MADE BY MARK ALL
PACKAGES AND
PAPERS WITH
IDENTIFICATION
NUMBERS IN
BLOCKS 1 AND 2.
16.
TYPE
OF
ORDER ACCEPTANCE.
(YYYYMMMDD)
17. ACCOUNTING AND APPROPRIATION DATA/LOCAL USE
18. ITEM NO. 19. SCHEDULE OF SUPPLIES/SERVICES
20. QUANTITY
ORDERED/
ACCEPTED*
21.
UNIT
22. UNIT PRICE 23. AMOUNT
* If quantity accepted by the Government is same as quantity ordered, indicate by X.
If different, enter actual quantity accepted below quantity ordered and encircle.
24. UNITED STATES OF AMERICA 25. TOTAL
26.
DIFFERENCES
27a. QUANTITY IN COLUMN 20 HAS BEEN
INSPECTED RECEIVED
ACCEPTED, AND CONFORMS TO
THE CONTRACT EXCEPT AS NOTED:
YYYYMMMDD
28. SHIP. NO. 29. D.O. VOUCHER NO. 30. INITIALS
32. PAID BY 33. AMOUNT VERIFIED CORRECT FOR
36. I CERTIFY THIS ACCOUNT IS CORRECT AND PROPER FOR PAYMENT.
YYYYMMMDD
DD FORM 1155, DEC 2001
37. RECEIVED
AT
38. RECEIVED BY Print 39. DATE RECEIVED
YYYYMMMDD
31. PAYMENT
40. TOTAL CON-
TAINERS
41. S/R ACCOUNT NUMBER 42. S/R VOUCHER NO.
34. CHECK NUMBER
35. BILL OF LADING NO.
X
XYZ Company
X
XXXXXXXXXXXXXXX
ATTACHMENT 1
sq90455 Typewritten Text Solicitation SP4520-13-R-0020
SECTION B
12 XX
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