TO0001PWS_AttachS_Sample_Customer_Concurrence_and_Release_Forms.pdf

ATTACHMENT 1

CERTIFICATE OF CUSTOMER CONCURRENCE

Reference: In accordance with FAR 32.9(c), the following is the minimum information that must be provided in order to process the Contractor’s invoice.

(1) Contract No:____________________________________________________________

(2) Delivery Order or Task Order No.: __________________________________________

(3) Contract Line Item No. (CLIN) and Subcontract Line Item No. (SLIN):_____________

(4) Description of supplies delivered or services performed (include project title and location): _______________________________________________________________

(5) Quantities of supplies received and accepted or services performed:

(6) Date(s) supplies delivered or services performed: _______________________________

(7) Contractor’s Invoice No.: __________________________________________________

(8) Contractor’s Invoice Amount:_______________________________________________

The supplies or services represented above have been accepted:

Signature

Printed Name

Title (print)

Organization, mailing address and telephone number (print)

Date Certified

Keller Army Community Hospital IO&T Attachment 15.14

ATTACHMENT 2

CONTRACTOR’S RELEASE

Contract Number: _______________

Project Description: ______________________________________________________

Pursuant to the terms of Contract No. ________________ and in consideration of the sum of $______ (contract total), of which $_______ (invoice amount) is being submitted for payment under the said Contract/Task Order to ________ (company name and address), hereinafter called “Contractor” or its assignees, if any, the Contractor upon full payment of said sum by the UNITED STATES OF AMERICA (hereinafter called “the Government”) does remise, release, and discharge the Government, its officers, agents, and employees, of and from all liabilities, obligations, claims, and demands whatsoever under or arising from the said Contract/Task Order.

IN WITNESS WHEREOF, this release has been executed on the ___ day of _________, 20__.

________________________ (Contractor)

By: ____________________________________ (signature) Name: ___________________ Title: ____________________

WITNESS: ______________________________ (signature)

Keller Army Community Hospital IO&T Attachment 15.14