Att0012_Item_Information_Certification_Statement_Template.doc
DOC document 49 KB Posted
- Attached to
- 13-NSA AND NSMWS 5 YEAR IDIQ SOLICITATION
- Solicitation number
- W52P1J-15-R-0072
About this file
ATTACHMENT 0012 ITEM INFORMATION CERTIFICATE STATEMENT
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Text version
IICS Control No:
Item Information and Certification Statement
(For OCONUS Use Only)
Date of Execution
Prime Contractor Name, Address, Phone number
Prime Contract Number
Contract Line Item Number (CLIN)
Transportation Control Number (TCN)
FMS Case Identifier
Item Description
Shipment Quantity
Total Number of Pallets
Year of Manufacture
Lot Number (Quantity)
Airport/Point of Embarkation
Supplier Name, City, Country
MAPAD/Final Destination
Airway Bill or Ocean Bill or Ground Bill of Lading Number
Shipment Number
1) Acknowledgement of visual inspection at source on behalf of the U.S. Government:
DCMA Representative (printed/typed/stamped)
Title and Contact Info
Signature of DCMA Representative
Date
2) Acknowledgement of receipt of the items on behalf of the U.S. Government and assumption of full responsibility for movement from this point forward:
U.S. Government Receiving Official (printed/typed/stamped) Title and Contact Info Signature of U.S. Government Receiving Official
Date
3) Acknowledgement of visual inspection, which includes kind, count, and condition of the packaging, marking, and palletization of the items on behalf of the U.S. Government:
U.S. Government Receiving Official (printed/typed/stamped) Title and Contact Info Signature of U.S. Government Receiving Official
Date
File details come from the government source that posted it. Updated .