Amend0001_SampleOrder_20B0003_Fence_20200311.pdf

6 . ISSUE D BY CODE

W912C3-XX-D-0000

1 . CO N TRA CT/P U RCH . O RD E R/

A G RE E M E N T N O .

W 912C 3

2 . D E L IVE R Y O R D E R / C A L L

N O .

W912C3xxxxxx

17P AGE 1 OF

5 . P RIO RITY

CODE W 912C 3

8 . DEL IVERY FOB

DEST INAT ION

OT HE R

(See Sch edule if o t h er)

OR D ER FOR SUPPLIES OR SER VICES

3 . D A TE O F O RD E R/CA L L 4 . RE Q ./ P U RCH . RE Q U E ST N O .

See Schedule

X

MIC C - F T BU C H AN AN

F T BU C H AN AN

D IR EC TOR ATE OF C ON TR AC TIN G

34 SOU TH GATE R D , STE 1104

F OR T BU C H AN AN PR 00934-4206

7 . ADM INIST E RE D BY (if o th er th a n 6 )

MIC C - F T BU C H AN AN

34 SOU TH GATE R D , STE 1104

F OR T BU C H AN AN PR 00934-4206

( YYYYM M M D D )

1 0 . D E L IVE R TO FO B P O IN T BY (D ate)

( YYYYM M M D D )

CODE9 . CONT RACT OR FACIL IT Y

SEE SCHEDULE

1 2 . D ISCO U N T TE RM S

N et 14 D ays

M A RK IF BU SIN E SS IS1 1 .

X

SM A L L

SM A L L

D ISA D VA N TA G E D

W O M E N -O W N E D

1 3 . M AIL INVOICE S T O T HE ADDRESS IN BLOCK

See Item 15

2 5 . T OT AL $

X

1 7 . ACCOUNT ING AND AP P ROP RIAT ION DAT A/ L OCAL USE

CODE

1 8 . IT E M NO. 1 9 . SCHEDUL E OF SUP P LIE S/ SERVICE S

* If q u a n t i ty a ccep ted b y th e G o ver n m en t is s a m e a s q u a n t i ty a ccep ted b elo w q u a n t i ty o r d er ed a n d en cir cle.

DE L IVE RY/1 6 .

1 4 . SHIP T O

Se e Sche dule

W 81Y D N H Q0490

MARK ALL

P AC KAG ES AND

P AP ERS W ITH

IDENTIFIC ATIO N

NUMB ERS IN

B LO C KS 1 AND 2 .

2 3 . AM OUNT

1 5 . P AYM ENT W IL L BE M ADE BY CODE

D F AS- IN D Y VP GF EBS

8899 E. 56TH ST

IN D IAN APOLIS IN 46249-3800

Th is d el iv ery o rd er/cal l i s i s s u ed o n an o th er G o v ern men t ag en cy o r in acco rd an ce w i th an d s u b ject to terms an d co n d i t io n s o f ab o v e n u mb ered co n tract .

T YP E CAL L

OF P URCHASE

ORDE R

SEE SCHEDULE

CONTRACTING / ORDERING OFFICER

q u a n t i ty o r d er ed , in d ica te b y X . If d i f f er en t , en ter a ctu a l

If t h is bo x is m ark ed, sup p lier m ust sign Accep t an ce an d ret urn t h e fo llo win g n um ber o f co p ies:

NAM E OF CONT RACT OR SIGNAT URE T YP E D NAM E AND T IT L E

( YYYYM M M D D )

DAT E SIGNE D

ACCE P T ANCE. T HE CONT RACT OR HE REBY ACCE P T S T HE OFFE R REP RESE NT ED BY T HE NUM BE RED P URCHASE ORDE R AS IT M AY P REVIOUSL Y HAVE BEE N OR IS NOW M ODIFIE D, SUBJE CT T O AL L OF T HE T E RM S

AND CONDIT IONS SE T FORT H, AND AGRE ES T O P ERFORM T HE SAM E.

Referen ce y o u r q u o te d ated

Fu rn is h th e fo l lo w in g o n terms s p eci fied h erein . REF :

2 0 . QUANT IT Y

ORDERE D/

ACCE P T ED*

2 1 . UNIT 2 2 . UNIT P RICE

D IFFE RE N CE S

2 6 .

INSP E CT E D RE CE IVED ACCEP T E D, AND CONFORM S T O T HE

CONT RACT EXCEP T AS NOT E D

2 7 a. QUANT IT Y IN COL UM N 2 0 HAS BE E N

( YYYYM M M D D )

c. DAT E d. P RINT E D NAM E AND T IT L E OF AUT HORIZ ED

GOVERNM E NT RE P RE SENT AT IVE

b. SIGNAT URE OF AUT HORIZ E D GOVE RNM E NT RE P RE SENT AT IVE

e. M AIL ING ADDRE SS OF AUT HORIZ ED GOVE RNM ENT REP RESE NT AT IVE

36. I ce r tify th is account is cor re ct and prope r for paym e nt.

g. E -M AIL ADDRESSf. T EL EP HONE NUM BE R

a. DAT E

( YYYYM M M D D )

b. SIGNAT URE AND T IT LE OF CE RT IFYING OFFICE R

2 8 . SHIP NO. 2 9 . DO VOUCHER NO. 3 0 .

INIT IAL S

3 2 . P AID BY 3 3 . AM OUNT VE RIFIED

CORRE CT FOR

3 5 . BIL L OF LADING NO.

3 4 . CHE CK NUM BE R

3 7 . RE CEIVED AT 3 8 . RECE IVE D BY

( YYYYM M M D D )

3 1 . P AYM E NT

COM P L ET E

P ART IAL

FINAL

P ART IAL

FINAL

DD For m 1155, DEC 2001 P RE VIOUS EDIT ION IS OBSOL ET E .

3 9 . DAT E RE CE IVED 4 0 . T OT AL

CONT AINERS

4 1 . S/R ACCOUNT NO. 4 2 . S/R VOUCHE R NO.

AD D R ESS

AN D

N AME

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AMEND 00

-S

AMPLE

TASK O

RDER

W912C3-XXXXXXX

W912C3XXXXXXX

Section 00010 - Solicitation Contract Form

ITEM NO SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT

0001 $0.00

Marker 29

FFP

Contractor shall provide labor, materials, equipment, supervision, incidentals, and all necessary to perform "Installation and Repair of Fences in Fort Buchanan, Puerto Rico" in accordance with the Statement of Work and all terms and conditions stated herein.

Work under this Contract will be performed via individual Delivery Orders.

PURCHASE REQUEST NUMBER: 00XXXXXXXXXX

NET AMT $0.00

ITEM NO SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT

0001AA 65 Linear

Foot $00.00 $

0005BC REPLACE 8 FEET FENCE, TYPE F-1

FFP

FOB: Destination

PURCHASE REQUEST NUMBER: 001

PSC CD: Z2PZ

NET AMT $

ACRN AA

CIN: GFEBS00

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AMPLE

ITEM NO SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT

0001AB 130 Linear

Foot

0005BP REPLACE BARBED WIRE

FFP

FOB: Destination

PURCHASE REQUEST NUMBER: 00

PSC CD: Z2PZ

NET AMT $

ACRN AA

CIN: GFEBS00

ITEM NO SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT

0001AC 65 Linear

Foot

0005BR REPLACE BARBED TAPE

FFP

FOB: Destination

PURCHASE REQUEST NUMBER: 00

PSC CD: Z2PZ

NET AMT $

ACRN AA

CIN: GFEBS00

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AMPLE

ITEM NO SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT

0001AD 6 Each $ $

0005BV REPLACE FENCE POST SP-3 SIZE 8 FE

FFP

REPLACE FENCE POST SP-3 SIZE 8 FEET FENCE AS INTERMEDIATE

POST

FOB: Destination

PURCHASE REQUEST NUMBER: 00

PSC CD: Z2PZ

NET AMT $

ACRN AA

CIN: GFEBS00

ITEM NO SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT

0001AE 6 Each $ $

0005BS REPLACE BARBED WIRE V-ARM TYPE

FFP

FOB: Destination

PURCHASE REQUEST NUMBER: 00

PSC CD: Z2PZ

NET AMT $

ACRN AA

CIN: GFEBS00

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AMPLE

ITEM NO SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT

0001AF 130 Linear $ $

NET AMT $

Foot

0005BT REPLACE TOP RAIL, SP-1 FOR ALL HE

FFP

REPLACE TOP RAIL, SP-1 FOR ALL HEIGHTS

FOB: Destination

PURCHASE REQUEST NUMBER: 00

PSC CD: Z2PZ

ACRN AA

CIN: GFEBS00

ITEM NO SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT

0002 $0.00

Ducks Lake

FFP

NET AMT $0.00

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AMPLE

ITEM NO SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT

0002AA 10 Linear

Foot

0005BC REPLACE 8 FEET FENCE, TYPE F-1

FFP

FOB: Destination

PURCHASE REQUEST NUMBER: 00

PSC CD: Z2PZ

NET AMT $

ACRN AC

CIN: GFEBS00

ITEM NO SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT

0002AB 10 Linear

Foot

0005BP REPLACE BARBED WIRE

FFP

FOB: Destination

PURCHASE REQUEST NUMBER: 00

PSC CD: Z2PZ

NET AMT $

ACRN AC

CIN: GFEBS00

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AMPLE

ITEM NO SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT

0002AC 10 Linear

Foot

0005BR REPLACE BARBED TAPE

FFP

FOB: Destination

PURCHASE REQUEST NUMBER: 00

PSC CD: Z2PZ

NET AMT $

ACRN AC

CIN: GFEBS00

ITEM NO SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT

0002AD 1 Linear $ $

NET AMT $

Foot

0005BQ REPLACE BARBED WIRE SINGLE ARM

FFP

FOB: Destination

PURCHASE REQUEST NUMBER: 00

PSC CD: Z2PZ

ACRN AC

CIN: GFEBS00

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AMPLE

ITEM NO SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT

0002AE 1 Each $ $

0005BV REPLACE FENCE POST SP-3 SIZE 8 FE

FFP

REPLACE FENCE POST SP-3 SIZE 8 FEET FENCE AS INTERMEDIATE

POST

FOB: Destination

PURCHASE REQUEST NUMBER: 00

PSC CD: Z2PZ

NET AMT $

ACRN AC

CIN: GFEBS00

ITEM NO SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT

0003 $0.00

Fence BLDG 545

FFP

NET AMT $0.00

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AMPLE

ITEM NO SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT

0003AA 6 Each $ $

0005BV REPLACE FENCE POST SP-3 SIZE 8 FE

FFP

REPLACE FENCE POST SP-3 SIZE 8 FEET FENCE AS INTERMEDIATE

POST

FOB: Destination

PURCHASE REQUEST NUMBER: 00

PSC CD: Z2PZ

NET AMT $

ACRN AB

CIN: GFEBS00

INSPECTION AND ACCEPTANCE TERMS

Supplies/services will be inspected/accepted at:

CLIN INSPECT AT INSPECT BY ACCEPT AT ACCEPT BY

0001 N/A N/A N/A N/A 0001AA Destination Government Destination Government 0001AB Destination Government Destination Government 0001AC Destination Government Destination Government 0001AD Destination Government Destination Government 0001AE Destination Government Destination Government 0001AF Destination Government Destination Government 0002 N/A N/A N/A N/A 0002AA Destination Government Destination Government 0002AB Destination Government Destination Government 0002AC Destination Government Destination Government 0002AD Destination Government Destination Government 0002AE Destination Government Destination Government 0003 N/A N/A N/A N/A 0003AA Destination Government Destination Government

DELIVERY INFORMATION

CLIN DELIVERY DATE QUANTITY SHIP TO ADDRESS DODAAC /

CAGE

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N/A N/A 0001 N/A

0001AA DATE 65 W81YDN

0001AB DATE 130 W81YDN

0001AC DATE 65 W81YDN

0001AD DATE 6 W81YDN

6 W81YDN

130 W81YDN

N/A N/A

10 W81YDN

10 W81YDN

10 W81YDN

1 W81YDN

1 W81YDN

N/A N/A

0001AE DATE

0001AF DATE

0002 N/A

0002AA DATE

0002AB DATE

0002AC DATE

0002AD DATE

0002AE DATE

0003 N/A

0003AA DATE 6

N/A

W1H1 USAG FT BUCHANAN

DPW 34TH SOUTH GATE ROAD

FORT BUCHANAN PR 00934-4572

787-707-xxxx FOB: Destination

(SAME AS PREVIOUS

LOCATION) FOB: Destination

(SAME AS PREVIOUS

LOCATION) FOB: Destination

(SAME AS PREVIOUS LOCATION)

FOB: Destination

(SAME AS PREVIOUS LOCATION)

FOB: Destination

(SAME AS PREVIOUS LOCATION)

FOB: Destination

N/A

W1H1 USAG FT BUCHANAN

DPW 34TH SOUTH GATE ROAD

FORT BUCHANAN PR 00934-4572

787-707-xxxx FOB: Destination

(SAME AS PREVIOUS

LOCATION) FOB: Destination

(SAME AS PREVIOUS

LOCATION) FOB: Destination

(SAME AS PREVIOUS LOCATION)

FOB: Destination

(SAME AS PREVIOUS LOCATION)

FOB: Destination

N/A

W1H1 USAG FT BUCHANAN

DPW 34TH SOUTH GATE ROAD

FORT BUCHANAN PR 00934-4572

787-707-xxxx FOB: Destination

W81YDN

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AMPLE

SOW MARKER 29

Statement of Work

Repair Damaged Fence at Marker 29

1. BACKGROUND: For several years Department of Public Works (DPW) has provided ongoing maintenance and improvement measures consistent with the Garrison and tenants needs.

2. OBJECTIVE: Repair Damaged Fence at Marker 29

3. SCOPE: The contractor shall provide all personnel, management equipment, materials and supplies to Repair Damaged Fence at Marker 29

3.1 Secure all required permits as per the contract.

3.2 Coordinate activity with COR to ensure access and continuation of tenant activities.

3.3 REPLACE 8 FEET FENCE, TYPE F-1 (65 LNFT.)

3.4 REPLACE BARBED WIRE (130 LNFT.)

3.5 REPLACE BARBED TAPE (65 LNFT.)

3.6 REPLACE BARBED WIRE V-ARM (6 EA.)

3.7 REPLACE TOP RAIL, SP-1 FOR (130 LNFT.)

3.8 REPLACE FENCE POST SP-3 ' SIZE 8 FENCE AS INTERMEDIATE POST (6EA.)

3.9 Upon completion clean areas of any debris or litter from fence installation activities.

4. APPLICABLE PERFORMANCE STANDARDS: The contractor shall install all structures in accordance with the terms and conditions of the base contract W912C3-XXXXXXX

5. DELIVERY SCHEDULE: The contractor shall complete installation within thirty (30) calendar days after contract award.

6. SPECIAL REQUIREMENTS: This is the Department of the Army Military Installation. The contractor shall:

6.1 Wear identification badges: Contractor personnel on duty shall wear Contractor provided identification badges displaying employee’s name, picture, position, signature, and name of Contractor. Identification badges shall be worn on the upper right front quadrant of the upper outer garment.

6.2 Provide personnel listing and DD Form 369 within three (3) calendar days after task order award to the Contracting Officer to obtain installation passes.

6.2 Security Considerations: Contractor personnel and property will be subject to search and seizure upon entering the gates of Fort Buchanan.

7. Place of Performance: Repair Damaged Fence at Marker 29

POC:

SOW DUCKS LAKE

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Statement of Work Repair Gates and fence at Ducks Lake nearby Antilles Middle School

1. BACKGROUND: For several years Department of Public Works (DPW) has provided ongoing maintenance and improvement measures consistent with the Garrison and tenants needs.

2. OBJECTIVE: Repair Gates and fence at Ducks Lake nearby Antilles Middle School.

3. SCOPE: The contractor shall provide all personnel, management equipment, materials and supplies to Repair Gates and fence at Ducks Lake nearby Antilles Middle School.

3.1 Secure all required permits as per the contract.

3.2 Coordinate activity with COR to ensure access and continuation of tenant activities. 3.3 REPLACE 8 FEET

FENCE, TYPE F-1 (10 LNFT.)

3.4 REPLACE BARBED WIRE (10 LNFT.)

3.5 REPLACE BARBED TAPE (10 LNFT.)

3.6 REPLACE BARBED WIRE SINGLE ARM (1 EA.)

3.7 REPLACE FENCE POST SP-3 ' SIZE 8 FENCE AS INTERMEDIATE POST (1 EA.)

3.8 Upon completion clean areas of any debris or litter from fence installation activities.

4. APPLICABLE PERFORMANCE STANDARDS: The contractor shall install all structures in accordance with the terms and conditions of the base contract W912C3-XXXXXXX

5. DELIVERY SCHEDULE: The contractor shall complete installation within ten (10) calendar days after contract award.

6. SPECIAL REQUIREMENTS: This is the Department of the Army Military Installation. The contractor shall:

6.1 Wear identification badges: Contractor personnel on duty shall wear Contractor provided identification badges displaying employee’s name, picture, position, signature, and name of Contractor. Identification badges shall be worn on the upper right front quadrant of the upper outer garment.

6.2 Provide personnel listing and DD Form 369 within three (3) calendar days after task order award to the Contracting Officer to obtain installation passes.

6.2 Security Considerations: Contractor personnel and property will be subject to search and seizure upon entering the gates of Fort Buchanan.

7. Place of Performance: Repair Gates and fence at Ducks Lake nearby Antilles Middle School.

POC:

SOW FENCE BLDG 545

Statement of Work

Repair Damaged Gates at building 545 Storm Water Retaining Pond.

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1. BACKGROUND: For several years Department of Public Works (DPW) has provided ongoing maintenance and improvement measures consistent with the Garrison and tenants needs.

2. OBJECTIVE: Repair Damaged Gates at building 545 Storm Water Retaining Pond.

3. SCOPE: The contractor shall provide all personnel, management equipment, materials and supplies to Repair Damaged Gates at building 545 Storm Water Retaining Pond.

3.1 Secure all required permits as per the contract.

3.2 Coordinate activity with COR to ensure access and continuation of tenant activities.

3.3 REPLACE FENCE POST SP-3 ' SIZE 8 FENCE AS INTERMEDIATE POST (6 LNFT.)

3.4 Upon completion clean areas of any debris or litter from fence installation activities.

4. APPLICABLE PERFORMANCE STANDARDS: The contractor shall install all structures in accordance with the terms and conditions of the base contract W912C3-XXXXXXX

5. DELIVERY SCHEDULE: The contractor shall complete installation within ten (10) calendar days after contract award.

6. SPECIAL REQUIREMENTS: This is the Department of the Army Military Installation. The contractor shall:

6.1 Wear identification badges: Contractor personnel on duty shall wear Contractor provided identification badges displaying employee’s name, picture, position, signature, and name of Contractor. Identification badges shall be worn on the upper right front quadrant of the upper outer garment.

6.2 Provide personnel listing and DD Form 369 within three (3) calendar days after task order award to the Contracting Officer to obtain installation passes.

6.2 Security Considerations: Contractor personnel and property will be subject to search and seizure upon entering the gates of Fort Buchanan.

7. Place of Performance: Repair Damaged Gates at building 545 Storm Water Retaining Pond.

POC:

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AMPLE

Section 00700 - Contract Clauses

CLAUSES INCORPORATED BY REFERENCE

52.204-9 Personal Identity Verification of Contractor Personnel JAN 2011 52.222-50 Combating Trafficking in Persons JAN 2019 52.232-27 Prompt Payment for Construction Contracts JAN 2017 252.211-7003 Item Unique Identification and Valuation MAR 2016 252.232-7003 Electronic Submission of Payment Requests and Receiving

Reports

DEC 2018

CLAUSES INCORPORATED BY FULL TEXT

252.232-7006 WIDE AREA WORKFLOW PAYMENT INSTRUCTIONS (DEC 2018)

(a) Definitions. As used in this clause—

“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) Electronic invoicing. The WAWF system provides the method to electronically process vendor 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) WAWF access. To access WAWF, the Contractor shall—

(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) WAWF training. The Contractor should follow the training instructions of the WAWF Web-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) WAWF methods of document submission. Document submissions may be via web entry, Electronic Data Interchange, or File Transfer Protocol.

(f) WAWF payment instructions. The Contractor shall use the following information when submitting payment requests and receiving reports in WAWF for this contract or task or delivery order:

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

(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.

(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.

DoD Contract Type: DoD Contract (FAR) Invoice Type: Construction

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

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

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

Issue By DoDAAC W912C3

Admin DoDAAC** W912C3

Inspect By DoDAAC W81YDN

Ship To Code W81YDN

Ship From Code ____

Mark For Code ____

Service Approver (DoDAAC) W81YDN

Service Acceptor (DoDAAC) W81YDN

Accept at Other DoDAAC ____

LPO DoDAAC ____

DCAA Auditor DoDAAC ____

Other DoDAAC(s):Contracting Officer W81YDN

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

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

Acceptor:

Contract Specialist:

Contracting Officer:

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

(End of clause)

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Section 00800 - Special Contract Requirements

ACCOUNTING AND APPROPRIATION DATA

AA: COST CODE:

AMOUNT: $

AB: COST CODE:

AMOUNT: $

AC: COST CODE:

AMOUNT: $

ACRN CLIN/SLIN AMOUNT

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AMPLE