J-3DDForm250.pdf

Attachment J-3 W91GDW-08-R-4019

MATERIAL INSPECTION AND RECEIVING REPORT Form Approved OM B No. 0704-0248

The public report ing burden for this collect ion of information is est imated to average 30 minutes per response, including the t ime for reviewing instruct ions, searching exist ing data sources, gathering, and maintaining the data needed, and complet ing and reviewing the collect ion of information. Send comments regarding this burden est imate or any other aspect of this collect ion of Informat ion, including suggestions for reducing this burden to Department of Defense, Washington Headquarters Services, Directorate for Information Operat ions and Reports, (0704-0248), 1215 Jef ferson Davis Highway, Suite 1204, Arlington, VA 22202-4302, Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty f ir failing to comply with a collect ion of informat ion if it does not display a current ly valid OM B control number.

P LEAS E DO NOT RETURN YOUR COM P LETED FORM TO EI THER OF THES E ADDR ES S ES .

S END THI S FORM I N ACCOR DANCE WI TH TH E I NS TRUC TI ONS CON TAI N ED I N TH E DFAR S , AP P END I X F- 4 0 1

1. PROC INSTRUMENT IDEN. (CONTRACT) (ORDER) NO. 6. INVOICE NO./ DATE 7. PAGE OF 8. ACCEPTANCE POINT

2. SHIPMENT NO. 3. DATE SHIPPED 4. B/ L 5. DISCOUNT TERMS

TCN

9. PRIME CONTRACTOR CODE 10. ADMINISTERED BY CODE

11. SHIPPED FROM ( If ot her t han 9) CODE FOB: 12. PAYMENT WILL BE MADE BY CODE

(EFT:T)

13. SHIPPED TO CODE 14. MARKED FOR CODE

15. 16. STOCK/PART NO DESCRIPTION 17. 18. 19. 20.

ITEM (Indicate number of shipping containers - type of QUANTITY UNIT UNIT PRICE AM OUNT NO container - container number.) SHIP/REC'D *

Amount Due $0.00

21. CONTRACT QUALITY ASSURANCE 22. RECEIVER'S USE

A. ORIGIN B. DESTINATION

CQA ACCEPTANCE of listed items CQA ACCEPTANCE of listed items has been has been made by me or under my supervisio made by me or under my supervision and they and they conform to contract, except as note conform to contract, except as noted herein or on herein or on supporting documents. supporting documents. DATE RECEIVED

GOVERNMENT REPRESENTATIVE

_ _ _ _ _ _ _ _ _ _ _ _ _ TYPED NAME

DATE DATE

GOVERNMENT REPRESENTATIVE TITLE:

TYPED NAME: TYPED NAME MAILING ADDRESS:

TITLE: TITLE:

MAILING ADDRESS: MAILING ADDRESS:

COMMERCIAL TELEPHONE

NUMBER;

COMMERCIAL TELEPHONE COMMERCIAL TELEPHONE * I f quant it y received by t he Government is t he NUMBER; NUMBER; same as q uant it y shipped , ind icat e b y a check mark, if d if f erent , ent er act ual quant it y re-ceived below quant it y shipped and encircle.

23. CONTRACTOR USE ONLY

Reference: Contractor Project Number:

DD FORM 250, AUG 2000 PREVIOUS EDITION IS OBSOLETE

SIGNATURE OF AUTHORIZED

GOVERNMENT REPRESENTATIVE

SIGNATURE OF AUTHORIZED

Quantities show in column 17 were received in apparent good condition except as noted.

SIGNATURE OF AUTHORIZED