## Change Request Number: 03-65 Date: 23 May 2003

**Title:** Updates to Procurement Toolbox Form Templates

# **Name:** Aileen C. Stafford

**Routing Symbol:** ASU-200

**Phone:** 202-267-9674

**Policy OR Guidance:** Guidance

**Section and/or Text Affected:** Procurement Toolbox

**Summary of Change:** Revision, addition and deletion to forms as
required.

**Reason for Change:** To provide usable, friendly and accurate
automated forms.

**Development, Review, and/or Concurrence:**

Reviewed by reviewer as prescribed in T1.9.1.

**Target Audience:** Source selection officials, contract officers,
product teams

**Potential Links within FAST for the Change:** N/A

#### Attachments: Language of change

### Briefing Planned: No

**ASAG Responsibilities:** Review and comment

  ----------------------------- --------------------------------- ---------------------------- ------------------------------------ --------------------------------------
  [**FAST                       [**HELP**](../../../tutidx.htm)   [**WHAT\'S                   [**COMMENTS**](../../../ocomm.htm)   [**SEARCH**](../../../findpageb.htm)
  HOME**](../../../index.htm)                                     NEW**](../../../fhome.htm)                                        

  ----------------------------- --------------------------------- ---------------------------- ------------------------------------ --------------------------------------

+-----------------------------------------------------------------------+
|   ------------------------------------------------------------------  |
|   **GUIDANCE**                                                        |
|                                                                       |
|   ------------------------------------------------------------------  |
|                                                                       |
| **Toolsets / Procurement Toolbox / Download Procurement Form          |
| Templates / FAA Procurement Forms** ~(Revised~ ~07/2003)~             |
|                                                                       |
| Listed are the forms which may be used with the Acquisition           |
| Management System. Click on the link to download the Microsoft Word   |
| document.                                                             |
|                                                                       |
| Please click on the following icons to view the forms.                |
|                                                                       |
| :- Download Word Document                                             |
|                                                                       |
| :- Browse HTML Document                                               |
|                                                                       |
|                                                                       |
|                                                                       |
|   ---------- -------------------------------------------------------- |
|   Download / Title                                                    |
|   Browse                                                              |
|                                                                       |
|              **ABSTRACT OF OFFERS**   \--\> (SF-1409)                 |
|                                                                       |
|              **ABSTRACT OF OFFERS - CONTINUATION**   \--\> (SF-1410)  |
|                                                                       |
|              **AFFIDAVIT OF INDIVIDUAL SURETY**   \--\> (SF-28)       |
|                                                                       |
|              **AMENDMENT OF SOLICITATION/MODIFICATION OF CONTRACT**   |
|              \--\> (SF-30)                                            |
|                                                                       |
|              **ARCHITECT-ENGINEER AND RELATED SERVICES                |
|              QUESTIONNAIRE**   \--\> (SF-254)                         |
|                                                                       |
|              **ARCHITECT-ENGINEER AND RELATED SERVICES QUESTIONNAIRE  |
|              FOR SPECIAL PROJECT**   \--\>(SF-255)                    |
|                                                                       |
|              **ARCHITECT-ENGINEER CONTRACT**   \--\> (SF-252)         |
|                                                                       |
|              **AWARD/CONTRACT**   \--\> (SF-26) (Revised 07/2003)     |
|                                                                       |
|              **BID BOND**   \--\> (SF-24)                             |
|                                                                       |
|              **BID BOND** - **ANNUAL**   \--\> (SF-34)                |
|                                                                       |
|              **BUSINESS DECLARATION**   \--\> ~(Revised\ 02/2001)~    |
|                                                                       |
|              **CAPITALIZATION FORM \--\> **                           |
|                                                                       |
|              **CAPITALIZATION OF LESSSOR COMPLIANCE \--\> Available   |
|              Soon**                                                   |
|                                                                       |
|              **CERTIFICATE OF APPOINTMENT**   \--\> SF-1402)          |
|                                                                       |
|              **CONSENT OF SURETY**   \--\> (SF-1414)                  |
|                                                                       |
|              **CONSENT OF SURETY AND INCREASE OF PENALTY \--\>        |
|              Available Soon**                                         |
|                                                                       |
|              **CONTRACT AWARD NOTIFICATION**   \--\> (DOT-4220.41)    |
|                                                                       |
|              **CONTRACT DATA REQUIREMENT LIST (CDRL)**   \--\>        |
|                                                                       |
|              **CONTRACT FACILITIES CAPITAL AND COST OF MONEY**        |
|              \--\> (DOT-4220.34)                                      |
|                                                                       |
|              **CONTRACT PRICING PROPOSAL COVER SHEET**   \--\>        |
|              (SF-1411)                                                |
|                                                                       |
|              **CONTRACT PRICING SUMMARY**   \--\> (DOT-4220.44)       |
|                                                                       |
|              **CONTRACTOR POSITION / SENSITIVITY LEVEL DESIGNATION    |
|              RECORD \--\> FAA Form 1600-77**                          |
|                                                                       |
|              **CONTRACTOR\'S RELEASE**   \--\> (DOT-4220.4) (Revised  |
|              07/2003)                                                 |
|                                                                       |
|              **CONTRACTOR\'S REQUEST FOR PROGRESS PAYMENT**   \--\>   |
|              (SF-1443)                                                |
|                                                                       |
|              **DATA ITEM DESCRIPTION**   \--\>                        |
|                                                                       |
|              **DETERMINATION OF PROSPECTIVE CONTRACTOR                |
|              RESPONSIBILITY**   \--\> (DOT-4220.1)                    |
|                                                                       |
|              **ELECTRONICS FUNDS TRANSFER FORM \--\> Available Soon** |
|                                                                       |
|              **FACILITY SECURITY CHECKLIST**                          |
|                                                                       |
|              **INVENTORY SCHEDULE A - METALS IN MILL PRODUCT FORM**   |
|              \--\> (SF-1426)                                          |
|                                                                       |
|              **INVENTORY SCHEDULE A - METALS IN MILL PRODUCT FORM     |
|              (CONTINUATION SHEET)**   \--\> (SF-1427)                 |
|                                                                       |
|              **INVENTORY SCHEDULE B**   \--\> (SF-1428)               |
|                                                                       |
|              **INVENTORY SCHEDULE B - CONTINUATION SHEET**   \--\>    |
|              (SF-1429)                                                |
|                                                                       |
|              **INVENTORY SCHEDULE C - WORK-IN-PROCESS**   \--\>       |
|              (SF-1430)                                                |
|                                                                       |
|              **INVENTORY SCHEDULE C - WORK-IN-PROCESS (CONTINUATION   |
|              SHEET)**   \--\> (SF-1431)                               |
|                                                                       |
|              **INVENTORY SCHEDULE D - SPECIAL TOOLING AND SPECIAL     |
|              TEST EQUIPMENT**   \--\> (SF-1432)                       |
|                                                                       |
|              **INVENTORY SCHEDULE D - SPECIAL TOOLING AND SPECIAL     |
|              TEST EQUIPMENT (CONTINUATION SHEET)**   \--\> (SF-1433)  |
|                                                                       |
|              **INVENTORY VERIFICATION SURVEY**   \--\> (SF-1423)      |
|                                                                       |
|              **LAND ON AN AIRPORT LEASE \--\> **                      |
|                                                                       |
|              **LAND ON AN AIRPORT LEASE \--\> **                      |
|                                                                       |
|              **LESSORS ANNUAL COST STATEMENT \--\> **                 |
|                                                                       |
|              **MATERIAL INSPECTION AND RECEIVING REPORT**             |
|              \--\>\_(DOT-4220.42)                                     |
|                                                                       |
|              **ORDER FOR SUPPLIES AND SERVICES**   \--\> (SF-347)     |
|                                                                       |
|              **ORDER FOR SUPPLIES AND SERVICES CONTINUED**   \--\>    |
|              (SF-348)                                                 |
|                                                                       |
|              **PAYMENT BOND**   \--\> (SF-25A)                        |
|                                                                       |
|              **PAYMENT BOND FOR OTHER THAN CONSTRUCTION CONTRACTS**   |
|              \--\> (SF-1416)                                          |
|                                                                       |
|              **PERFORMANCE BOND -ANNUAL **   \--\> Template No.       |
|              18\_(SF-35)                                              |
|                                                                       |
|              **PERFORMANCE EVALUATION (ARCHITECT-ENGINEER)**   \--\>  |
|              (SF-1421)                                                |
|                                                                       |
|              **PREAWARD SURVEY OF PROSPECTIVE CONTRACTOR**            |
|              \--\>(SF-1403)                                           |
|                                                                       |
|              **PREAWARD SURVEY OF PROSPECTIVE CONTRACTOR (ACCOUNTING  |
|              SYSTEM)**   \--\> (SF-1408)                              |
|                                                                       |
|              **PREAWARD SURVEY OF PROSPECTIVE CONTRACTOR (FINANCIAL   |
|              CAPABILITY)**   \--\> (SF-1407)                          |
|                                                                       |
|              **PREAWARD SURVEY OF PROSPECTIVE CONTRACTOR (QUALITY     |
|              ASSURANCE)**   \--\> (SF-1406)                           |
|                                                                       |
|              **PREAWARD SURVEY OF PROSPECTIVE CONTRACTOR              |
|              (PRODUCTION)**   \--\> (SF-1405)                         |
|                                                                       |
|              **PREAWARD SURVEY OF PROSPECTIVE CONTRACTOR              |
|              (TECHNICAL)**   \--\> (SF-1404)                          |
|                                                                       |
|              **PRECONSTRUCTION CONFERENCE AGENDA AND CHECKLIST**      |
|              \--\> (DOT-4220.3)                                       |
|                                                                       |
|              **PROCUREMENT REQUEST**   \--\> (DOT-4200.1)             |
|                                                                       |
|              **PROCUREMENT REQUEST CONTINUATION FORM**                |
|              \--\>(DOT-4200.2)                                        |
|                                                                       |
|              **PROPOSAL COVER SHEET**   \--\>(SF-1448)                |
|                                                                       |
|              **PROPOSAL TO LEASE SPACE**                              |
|                                                                       |
|              **PROPOSED FEDERAL CONSTRUCTION REPORT \--\>** (FAA      |
|              4474-5) ~(Added\ 07/2002)~                               |
|                                                                       |
|              **RANDOLPH-SHEPPARD VENDING FACILITIES                   |
|              REPORT\--\>**(Interagency report 1270-ED-AN)             |
|              ~(Added\ 07/2002)~                                       |
|                                                                       |
|              **REINSURANCE AGREEMENT FOR A MILLER ACT PERFORMANCE     |
|              BOND**   \--\> (SF-2731)                                 |
|                                                                       |
|              **REINSURANCE AGREEMENT FOR A MILLER ACT PAYMENT BOND**  |
|                \--\>(SF-274)                                          |
|                                                                       |
|              **REQUEST FOR QUOTATION**   \--\>(SF-18)                 |
|                                                                       |
|              **RESOURCE CONSERVATION AND RECOVERY REPORT** (OST       |
|              Interagency Report)** ** ~(Revised\ 07/2003)~            |
|                                                                       |
|              **SEMI-ANNUAL LABOR COMPLIANCE REPORT** (DOL Interagency |
|              Report)** ** ~(Added\ 07/2002)~                          |
|                                                                       |
|              **SETTLEMENT PROPOSAL (SHORT FORM)**   \--\> (SF-1438)   |
|                                                                       |
|              **SMALL BUSINESS SET - ASIDE DETERMINATION AND           |
|              COORDINATION \--\>**~(Added\ 02/2001)~                   |
|                                                                       |
|              **SOLICITATION/CONTRACT**   \--\> \_(SF-1447)            |
|                                                                       |
|              **SOLICITATION, OFFER, AND AWARD**   \--\> (SF-33)       |
|                                                                       |
|              **SOLICITATION, OFFER, AND AWARD**   \--\> (SF-1442)     |
|                                                                       |
|              **SPACE ACTION SUMMARY \--\>**                           |
|                                                                       |
|              **SPACE LEASE -ATTACHMENT A \--\>**                      |
|                                                                       |
|              **SPACE LEASE FORM \--\> **                              |
|                                                                       |
|              **SPACE MARKET SURVEY FORM \--\> **                      |
|                                                                       |
|              **SPACE SAFETY AND ENVIRONMENTAL CHECKLIST \--\> **      |
|                                                                       |
|              **SPACE SOLICITATION INFORMATION \--\> **                |
|                                                                       |
|              **STATEMENT AND ACKNOWLEDGEMENT**   \--\> Template No.   |
|              21\_(SF-1413)                                            |
|                                                                       |
|              **SUBCONTRACTING REPORT FOR INDIVIDUAL CONTRACTS**       |
|              \--\> (SF-294)                                           |
|                                                                       |
|              **SUMMARY SUBCONTRACT REPORT (SF-295) \-- \>** (Revised  |
|              07/2003)                                                 |
|                                                                       |
|              **SUPPORT CONTRACT AUTHORIZATION \--\>** (Revised        |
|              07/2003)                                                 |
|                                                                       |
|              **TERMINATION INVENTORY SCHEDULE E - SHORT FORM FOR USE  |
|              WITH SF-1438 ONLY**   \--\> (SF-1434)                    |
|                                                                       |
|              **UTILITY APPLICATION \--\> **                           |
|                                                                       |
|              **URGENT DATA REQUEST ** ~(Added\ 10/2002)~              |
|                                                                       |
|              **WEIGHTED GUIDELINES**   \--\> (DOT-4220.32)** **       |
|                                                                       |
|                                                                       |
|   ---------- -------------------------------------------------------- |
|                                                                       |
|                                                                       |
+-----------------------------------------------------------------------+

<table>
<colgroup>
<col style="width: 2%" />
<col style="width: 1%" />
<col style="width: 1%" />
<col style="width: 29%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 0%" />
<col style="width: 0%" />
<col style="width: 8%" />
<col style="width: 1%" />
<col style="width: 2%" />
<col style="width: 2%" />
<col style="width: 5%" />
<col style="width: 0%" />
<col style="width: 4%" />
<col style="width: 5%" />
<col style="width: 5%" />
<col style="width: 5%" />
<col style="width: 5%" />
<col style="width: 2%" />
<col style="width: 2%" />
<col style="width: 5%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="22"><p><strong>DEPARTMENT OF TRANSPORTATION</strong></p>
<h2 id="contractors-release">CONTRACTOR’S RELEASE</h2></td>
</tr>
<tr class="even">
<td colspan="5">CONTRACT NO.</td>
<td colspan="17">CONTRACTOR (Name and Address)</td>
</tr>
<tr class="odd">
<td colspan="5">SUM OF</td>
<td colspan="17">DOLLARS</td>
</tr>
<tr class="even">
<td colspan="22"><p>In consideration of the sum stated above, which has
been paid or is to be paid to the Contractor, or his assignee, the
Contractor, upon payment of the 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, except:</p>
<p>1. Specified claims in stated amounts or in estimated amounts where
the amounts are not susceptible of exact statement by the Contractor, as
follows:</p></td>
</tr>
<tr class="odd">
<td colspan="22">2. Claims, together with reasonable expenses incidental
thereto, based upon the liabilities of the Contractor to third parties
arising out of the performance of this contract, which are not known to
the Contractor on the date of the execution of this release and of which
the Contractor gives notice in writing to the Contracting Officer within
the period specified in the said contract, and</td>
</tr>
<tr class="even">
<td colspan="22">3. Claims for reimbursement of costs (other than
expenses of the Contractor by reason of his indemnification of the
Government against patent liability), including reasonable expenses
incidental thereto, incurred by the Contractor under any provisions of
the said contract relating to patents.</td>
</tr>
<tr class="odd">
<td colspan="22"><p>The Contractor agrees, in connection with patent
matters and with claims which are not released as set forth above, that
he will comply with all provisions of the said contract, including
without limitations those provisions relating to notification to the
Contracting Officer and relating to the defense or prosecution of
litigation.</p>
<p>IN WITNESS WHEREOF, this release has been executed this day of , 20
.</p></td>
</tr>
<tr class="even">
<td colspan="8">WITNESS</td>
<td colspan="9">(Contractor)</td>
<td colspan="5"></td>
</tr>
<tr class="odd">
<td colspan="4"></td>
<td></td>
<td colspan="3">BY</td>
<td colspan="9"></td>
<td colspan="5"></td>
</tr>
<tr class="even">
<td colspan="4"></td>
<td colspan="3">TITLE</td>
<td colspan="11"></td>
<td colspan="4"></td>
</tr>
<tr class="odd">
<td colspan="4"></td>
<td colspan="4"></td>
<td colspan="9"></td>
<td colspan="5"></td>
</tr>
<tr class="even">
<td colspan="22"><strong>NOTE:</strong> In the case of a corporation,
witnesses are not required but the certification below must be
completed.</td>
</tr>
<tr class="odd">
<td colspan="22"><strong>CERTIFICATE</strong></td>
</tr>
<tr class="even">
<td colspan="2">I,</td>
<td colspan="12"></td>
<td colspan="6">, certify that I am the</td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td></td>
<td colspan="5"></td>
<td colspan="16">secretary of the corporation named as Contractor in the
foregoing release;</td>
</tr>
<tr class="even">
<td colspan="3">that</td>
<td colspan="6"></td>
<td colspan="13">who signed said release on behalf of the Contractor was
then</td>
</tr>
<tr class="odd">
<td></td>
<td colspan="10"></td>
<td colspan="11">of said corporation; that said release was duly signed
for</td>
</tr>
<tr class="even">
<td></td>
<td colspan="21">and in behalf of said corporation by authority of its
governing body and is within the scope of its corporate powers.</td>
</tr>
<tr class="odd">
<td colspan="22"></td>
</tr>
<tr class="even">
<td colspan="10">(CORPORATE SEAL)</td>
<td colspan="2"></td>
<td></td>
<td colspan="2"></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td colspan="2"></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="22"></td>
</tr>
</tbody>
</table>

<table style="width:100%;">
<colgroup>
<col style="width: 3%" />
<col style="width: 4%" />
<col style="width: 0%" />
<col style="width: 27%" />
<col style="width: 0%" />
<col style="width: 5%" />
<col style="width: 7%" />
<col style="width: 0%" />
<col style="width: 3%" />
<col style="width: 4%" />
<col style="width: 1%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 0%" />
<col style="width: 14%" />
<col style="width: 0%" />
<col style="width: 0%" />
<col style="width: 0%" />
<col style="width: 5%" />
<col style="width: 0%" />
<col style="width: 7%" />
<col style="width: 0%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="5"><strong>AWARD/CONTRACT</strong></td>
<td colspan="8">1. THIS CONTRACT IS A RATED ORDER UNDER DPAS (15 CFR
350)</td>
<td colspan="2">RATING</td>
<td colspan="5">PAGE</td>
<td colspan="2">OF PAGES</td>
</tr>
<tr class="even">
<td colspan="5">2. CONTRACT <em>(Proc. Inst. Ident.)</em> NO.</td>
<td colspan="6">3. EFFECTIVE DATE</td>
<td colspan="11">4. REQUISITION/PURCHASE REQUEST/PROJECT NO.</td>
</tr>
<tr class="odd">
<td colspan="5"></td>
<td colspan="6"></td>
<td colspan="11"></td>
</tr>
<tr class="even">
<td colspan="9">5. ISSUED BY</td>
<td colspan="13">6. ADMINISTERED BY <em>(If other than Block
5)</em></td>
</tr>
<tr class="odd">
<td colspan="9"></td>
<td colspan="13"></td>
</tr>
<tr class="even">
<td colspan="9">7. NAME AND ADDRESS OF CONTRACTOR <em>(No., street,
city, county, State and Zip Code)</em></td>
<td colspan="13">8. DELIVERY</td>
</tr>
<tr class="odd">
<td colspan="9"></td>
<td colspan="13"><p>FOB ORIGIN OTHER (<em>See Below</em>)</p>
<p>9. DISCOUNT FOR PROMPT PAYMENT</p>
<p>10. SUBMIT INVOICES<em>(4 copies unless otherwise specified)</em></p>
<p>TO THE ADDRESS SHOWN IN ITEM</p></td>
</tr>
<tr class="even">
<td colspan="9">11. SHIP TO/MARK FOR</td>
<td colspan="13">12. PAYMENT WILL BE MADE BY</td>
</tr>
<tr class="odd">
<td colspan="9"></td>
<td colspan="13"></td>
</tr>
<tr class="even">
<td colspan="9">13. RESERVED</td>
<td colspan="13">14. ACCOUNTING AND APPROPRIATION DATA</td>
</tr>
<tr class="odd">
<td colspan="9"></td>
<td colspan="13"></td>
</tr>
<tr class="even">
<td colspan="2"><p>15A.</p>
<p>ITEM NO.</p></td>
<td colspan="7"><p>15B.</p>
<p>SUPPLIES/SERVICES</p></td>
<td colspan="3"><p>15C.</p>
<p>QUANTITY</p></td>
<td colspan="2"><p>15D.</p>
<p>UNIT</p></td>
<td colspan="2"><p>15E.</p>
<p>UNIT PRICE</p></td>
<td colspan="5"><p>15F.</p>
<p>AMOUNT</p></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="2"></td>
<td colspan="7"></td>
<td colspan="3"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="5"></td>
<td></td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td colspan="7"></td>
<td colspan="3"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="5"></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="2"></td>
<td colspan="7"></td>
<td colspan="3"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="5"></td>
<td></td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td colspan="7"></td>
<td colspan="3"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="5"></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="2"></td>
<td colspan="7"></td>
<td colspan="3"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="5"></td>
<td></td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td colspan="7"></td>
<td colspan="3"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="5"></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="2"></td>
<td colspan="7"></td>
<td colspan="3"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="5"></td>
<td></td>
</tr>
<tr class="even">
<td colspan="17">15G. TOTAL AMOUNT OF CONTRACT</td>
<td colspan="5"></td>
</tr>
<tr class="odd">
<td colspan="22"><strong>16. TABLE OF CONTENTS</strong></td>
</tr>
<tr class="even">
<td>(X)</td>
<td colspan="2">SEC</td>
<td colspan="3">DESCRIPTION</td>
<td colspan="2">PAGE(S)</td>
<td>(X)</td>
<td>SEC</td>
<td colspan="9">DESCRIPTION</td>
<td colspan="3">PAGE(S)</td>
</tr>
<tr class="odd">
<td colspan="8"><strong>PART I - THE SCHEDULE</strong></td>
<td colspan="14"><strong>PART II - CONTRACT CLAUSES</strong></td>
</tr>
<tr class="even">
<td></td>
<td colspan="2">A</td>
<td colspan="3">SOLICITATION/CONTRACT FORM</td>
<td colspan="2"></td>
<td></td>
<td>I</td>
<td colspan="9">CONTRACT CLAUSES</td>
<td colspan="3"></td>
</tr>
<tr class="odd">
<td></td>
<td colspan="2">B</td>
<td colspan="3">SUPPLIES OR SERVICES AND PRICES/COSTS</td>
<td colspan="2"></td>
<td colspan="14"><strong>PART III - LIST OF DOCUMENTS, EXHIBITS, AND
OTHER ATTACH.</strong></td>
</tr>
<tr class="even">
<td></td>
<td colspan="2">C</td>
<td colspan="3">DESCRIPTION/SPECS/WORK STATEMENT</td>
<td colspan="2"></td>
<td></td>
<td>J</td>
<td colspan="9">LIST OF ATTACHMENTS</td>
<td colspan="3"></td>
</tr>
<tr class="odd">
<td></td>
<td colspan="2">D</td>
<td colspan="3">PACKAGING AND MARKING</td>
<td colspan="2"></td>
<td colspan="14"><strong>PART IV - REPRESENTATIONS AND
INSTRUCTIONS</strong></td>
</tr>
<tr class="even">
<td></td>
<td colspan="2">E</td>
<td colspan="3">INSPECTION AND ACCEPTANCE</td>
<td colspan="2"></td>
<td></td>
<td>K</td>
<td colspan="9">REPRESENTATIONS, CERTIFICATIONS AND</td>
<td colspan="3"></td>
</tr>
<tr class="odd">
<td></td>
<td colspan="2">F</td>
<td colspan="3">DELIVERIES OR PERFORMANCE</td>
<td colspan="2"></td>
<td></td>
<td></td>
<td colspan="9">OTHER STATEMENTS OF OFFERORS</td>
<td colspan="3"></td>
</tr>
<tr class="even">
<td></td>
<td colspan="2">G</td>
<td colspan="3">CONTRACT ADMINISTRATION DATA</td>
<td colspan="2"></td>
<td></td>
<td>L</td>
<td colspan="9">INSTRS., CONDS., AND NOTICES TO OFFERORS</td>
<td colspan="3"></td>
</tr>
<tr class="odd">
<td></td>
<td colspan="2">H</td>
<td colspan="3">SPECIAL CONTRACT REQUIREMENTS</td>
<td colspan="2"></td>
<td></td>
<td>M</td>
<td colspan="9">EVALUATION FACTORS FOR AWARD</td>
<td colspan="3"></td>
</tr>
<tr class="even">
<td colspan="22"><em><strong>CONTRACTING OFFICER WILL COMPLETE 17 OR 18
AS APPLICABLE</strong></em></td>
</tr>
<tr class="odd">
<td colspan="7">17. <strong>CONTRACTOR’S NEGOTIATED AGREEMENT</strong>
(Contractor is required to sign this document and return copies to
issuing office.) Contractor agrees to furnish and deliver all items or
perform all the services set forth or otherwise identified above and on
any continuation sheets for the consideration stated herein. The rights
and obligations of the parties to this contract shall be subject to and
governed by the following documents: (a) this award/contract, (b) the
solicitation, if and, and (c) such provisions, representations,
certifications and specifications, as are attached or incorporated by
reference herein. <em>(Attachment are listed herein.)</em></td>
<td colspan="15"><p>18. <strong>AWARD</strong> (Contractor is not
required to sign this document.) Your offer on Solicitation Number ,</p>
<p>including the additions or changes made by you which additions or
changes are set forth in full above, is hereby accepted as to the items
listed above and on any continuation sheets. This award consummates the
contract which consists of the following documents: (a) Government’s
solicitation and our offer, and (b) this award/contract. No further
contractual document is necessary.</p></td>
</tr>
<tr class="even">
<td colspan="7">19A. NAME AND TITLE OF SIGNER <em>(Type or
print)</em></td>
<td colspan="15">20A. NAME OF CONTRACTING OFFICER</td>
</tr>
<tr class="odd">
<td colspan="7"></td>
<td colspan="15"></td>
</tr>
<tr class="even">
<td colspan="4">19B. NAME OF CONTRACTOR</td>
<td colspan="3">19C. DATE SIGNED</td>
<td colspan="11">20B. UNITED STATES OF AMERICA</td>
<td colspan="4">20C. DATE SIGNED</td>
</tr>
<tr class="odd">
<td colspan="4"><p>BY</p>
<p><em>(Signature of person authorized to sign)</em></p></td>
<td colspan="3"></td>
<td colspan="11"><p>BY</p>
<p><em>(Signature of Contracting Officer)</em></p></td>
<td colspan="4"></td>
</tr>
</tbody>
</table>

+---------+---+----------+------------+--------------+------+---+---------+
| **      |   |          |            |              |      |   |         |
| SUPPORT |   |          |            |              |      |   |         |
| CON     |   |          |            |              |      |   |         |
| TRACTOR |   |          |            |              |      |   |         |
| AUTHOR  |   |          |            |              |      |   |         |
| IZATION |   |          |            |              |      |   |         |
| *(FAA   |   |          |            |              |      |   |         |
| Sp      |   |          |            |              |      |   |         |
| onsored |   |          |            |              |      |   |         |
| Train   |   |          |            |              |      |   |         |
| ing)*** |   |          |            |              |      |   |         |
+---------+---+----------+------------+--------------+------+---+---------+
| #       |   |          |            |              |      |   |         |
|  SECTIO |   |          |            |              |      |   |         |
| N A. To |   |          |            |              |      |   |         |
|  Be Com |   |          |            |              |      |   |         |
| pleted  |   |          |            |              |      |   |         |
| by Supp |   |          |            |              |      |   |         |
| ort Con |   |          |            |              |      |   |         |
| tractor |   |          |            |              |      |   |         |
+---------+---+----------+------------+--------------+------+---+---------+
| 1\.     |   |          |            | 2\.          |      |   |         |
| Requ    |   |          |            | Requestor's  |      |   |         |
| estor's |   |          |            | Company &    |      |   |         |
| Name    |   |          |            | Address      |      |   |         |
| *       |   |          |            |              |      |   |         |
| (person |   |          |            |              |      |   |         |
| who     |   |          |            |              |      |   |         |
| wishes  |   |          |            |              |      |   |         |
| to take |   |          |            |              |      |   |         |
| tra     |   |          |            |              |      |   |         |
| ining)* |   |          |            |              |      |   |         |
+---------+---+----------+------------+--------------+------+---+---------+
|         |   |          |            |              |      |   |         |
+---------+---+----------+------------+--------------+------+---+---------+
| 3\.     |   |          |            | 4\.          |      |   |         |
| Requ    |   |          |            | Requestor's  |      |   |         |
| estor's |   |          |            | telephone    |      |   |         |
| Title   |   |          |            | number       |      |   |         |
+---------+---+----------+------------+--------------+------+---+---------+
|         |   |          |            |              |      |   |         |
+---------+---+----------+------------+--------------+------+---+---------+
| 5\.     |   |          |            |              |      |   |         |
| Support |   |          |            |              |      |   |         |
| C       |   |          |            |              |      |   |         |
| ontract |   |          |            |              |      |   |         |
| number  |   |          |            |              |      |   |         |
+---------+---+----------+------------+--------------+------+---+---------+
| 6\.     |   |          |            |              | 7\.  |   |         |
| Course  |   |          |            |              | D    |   |         |
| Title   |   |          |            |              | ates |   |         |
|         |   |          |            |              | of   |   |         |
|         |   |          |            |              | Co   |   |         |
|         |   |          |            |              | urse |   |         |
+---------+---+----------+------------+--------------+------+---+---------+
| 8\.     |   |          |            |              |      |   |         |
| Con     |   |          |            |              |      |   |         |
| tractor |   |          |            |              |      |   |         |
| Officer |   |          |            |              |      |   |         |
| must    |   |          |            |              |      |   |         |
| select  |   |          |            |              |      |   |         |
| A or B: |   |          |            |              |      |   |         |
+---------+---+----------+------------+--------------+------+---+---------+
| A.      |   |          |            |              |      |   |         |
| Con     |   |          |            |              |      |   |         |
| tractor |   |          |            |              |      |   |         |
| St      |   |          |            |              |      |   |         |
| atement |   |          |            |              |      |   |         |
| *       |   |          |            |              |      |   |         |
| (unique |   |          |            |              |      |   |         |
| con     |   |          |            |              |      |   |         |
| tent).* |   |          |            |              |      |   |         |
| The     |   |          |            |              |      |   |         |
| Con     |   |          |            |              |      |   |         |
| tractor |   |          |            |              |      |   |         |
| agrees  |   |          |            |              |      |   |         |
| that if |   |          |            |              |      |   |         |
| FAA     |   |          |            |              |      |   |         |
| allows  |   |          |            |              |      |   |         |
| re      |   |          |            |              |      |   |         |
| questor |   |          |            |              |      |   |         |
| to      |   |          |            |              |      |   |         |
| attend  |   |          |            |              |      |   |         |
| the     |   |          |            |              |      |   |         |
| above   |   |          |            |              |      |   |         |
| course, |   |          |            |              |      |   |         |
| then    |   |          |            |              |      |   |         |
| att     |   |          |            |              |      |   |         |
| endance |   |          |            |              |      |   |         |
| is on a |   |          |            |              |      |   |         |
| s       |   |          |            |              |      |   |         |
| pace-av |   |          |            |              |      |   |         |
| ailable |   |          |            |              |      |   |         |
| basis,  |   |          |            |              |      |   |         |
| AND the |   |          |            |              |      |   |         |
| FAA     |   |          |            |              |      |   |         |
| **WILL  |   |          |            |              |      |   |         |
| NOT**   |   |          |            |              |      |   |         |
| pay     |   |          |            |              |      |   |         |
| direct  |   |          |            |              |      |   |         |
| hourly  |   |          |            |              |      |   |         |
| charges |   |          |            |              |      |   |         |
| ass     |   |          |            |              |      |   |         |
| ociated |   |          |            |              |      |   |         |
| with    |   |          |            |              |      |   |         |
| the     |   |          |            |              |      |   |         |
| number  |   |          |            |              |      |   |         |
| of      |   |          |            |              |      |   |         |
| hours   |   |          |            |              |      |   |         |
| spent   |   |          |            |              |      |   |         |
| in the  |   |          |            |              |      |   |         |
| tr      |   |          |            |              |      |   |         |
| aining. |   |          |            |              |      |   |         |
|         |   |          |            |              |      |   |         |
| B.      |   |          |            |              |      |   |         |
| Con     |   |          |            |              |      |   |         |
| tractor |   |          |            |              |      |   |         |
| St      |   |          |            |              |      |   |         |
| atement |   |          |            |              |      |   |         |
| *       |   |          |            |              |      |   |         |
| (unique |   |          |            |              |      |   |         |
| con     |   |          |            |              |      |   |         |
| tent).* |   |          |            |              |      |   |         |
| The     |   |          |            |              |      |   |         |
| Con     |   |          |            |              |      |   |         |
| tractor |   |          |            |              |      |   |         |
| agrees  |   |          |            |              |      |   |         |
| that if |   |          |            |              |      |   |         |
| FAA     |   |          |            |              |      |   |         |
| allows  |   |          |            |              |      |   |         |
| re      |   |          |            |              |      |   |         |
| questor |   |          |            |              |      |   |         |
| to      |   |          |            |              |      |   |         |
| attend  |   |          |            |              |      |   |         |
| the     |   |          |            |              |      |   |         |
| above   |   |          |            |              |      |   |         |
| course, |   |          |            |              |      |   |         |
| then    |   |          |            |              |      |   |         |
| att     |   |          |            |              |      |   |         |
| endance |   |          |            |              |      |   |         |
| is on a |   |          |            |              |      |   |         |
| s       |   |          |            |              |      |   |         |
| pace-av |   |          |            |              |      |   |         |
| ailable |   |          |            |              |      |   |         |
| basis,  |   |          |            |              |      |   |         |
| AND the |   |          |            |              |      |   |         |
| FAA     |   |          |            |              |      |   |         |
| *       |   |          |            |              |      |   |         |
| *WILL** |   |          |            |              |      |   |         |
| pay     |   |          |            |              |      |   |         |
| direct  |   |          |            |              |      |   |         |
| hourly  |   |          |            |              |      |   |         |
| charges |   |          |            |              |      |   |         |
| ass     |   |          |            |              |      |   |         |
| ociated |   |          |            |              |      |   |         |
| with    |   |          |            |              |      |   |         |
| the     |   |          |            |              |      |   |         |
| number  |   |          |            |              |      |   |         |
| of      |   |          |            |              |      |   |         |
| hours   |   |          |            |              |      |   |         |
| spent   |   |          |            |              |      |   |         |
| in the  |   |          |            |              |      |   |         |
| t       |   |          |            |              |      |   |         |
| raining |   |          |            |              |      |   |         |
| as      |   |          |            |              |      |   |         |
| p       |   |          |            |              |      |   |         |
| rovided |   |          |            |              |      |   |         |
| in the  |   |          |            |              |      |   |         |
| pro     |   |          |            |              |      |   |         |
| visions |   |          |            |              |      |   |         |
| of the  |   |          |            |              |      |   |         |
| FAA     |   |          |            |              |      |   |         |
| c       |   |          |            |              |      |   |         |
| ontract |   |          |            |              |      |   |         |
| ide     |   |          |            |              |      |   |         |
| ntified |   |          |            |              |      |   |         |
| in line |   |          |            |              |      |   |         |
| 5..     |   |          |            |              |      |   |         |
+---------+---+----------+------------+--------------+------+---+---------+
| 9\.     |   |          |            |              |      |   |         |
| Justif  |   |          |            |              |      |   |         |
| ication |   |          |            |              |      |   |         |
| to      |   |          |            |              |      |   |         |
| Attend  |   |          |            |              |      |   |         |
| T       |   |          |            |              |      |   |         |
| raining |   |          |            |              |      |   |         |
+---------+---+----------+------------+--------------+------+---+---------+
|         |   |          |            |              |      |   |         |
+---------+---+----------+------------+--------------+------+---+---------+
| 10\.    |   |          |            | 11\. Date    |      |   |         |
| Si      |   |          |            |              |      |   |         |
| gnature |   |          |            |              |      |   |         |
| of      |   |          |            |              |      |   |         |
| Requ    |   |          |            |              |      |   |         |
| estor's |   |          |            |              |      |   |         |
| Manager |   |          |            |              |      |   |         |
+---------+---+----------+------------+--------------+------+---+---------+
|         |   |          |            |              |      |   |         |
+---------+---+----------+------------+--------------+------+---+---------+
| 12\.    |   |          |            | 13\.         |      |   |         |
| Ma      |   |          |            | Telephone    |      |   |         |
| nager's |   |          |            | Number       |      |   |         |
| Nam     |   |          |            |              |      |   |         |
| e/Title |   |          |            |              |      |   |         |
| *(      |   |          |            |              |      |   |         |
| printed |   |          |            |              |      |   |         |
| or      |   |          |            |              |      |   |         |
| typed)* |   |          |            |              |      |   |         |
+---------+---+----------+------------+--------------+------+---+---------+
|         |   |          |            |              |      |   |         |
+---------+---+----------+------------+--------------+------+---+---------+
| **      |   |          |            |              |      |   |         |
| SECTION |   |          |            |              |      |   |         |
| B. To   |   |          |            |              |      |   |         |
| Be      |   |          |            |              |      |   |         |
| Co      |   |          |            |              |      |   |         |
| mpleted |   |          |            |              |      |   |         |
| by FAA  |   |          |            |              |      |   |         |
| Cont    |   |          |            |              |      |   |         |
| racting |   |          |            |              |      |   |         |
| Of      |   |          |            |              |      |   |         |
| ficer** |   |          |            |              |      |   |         |
+---------+---+----------+------------+--------------+------+---+---------+
| 14\.    |   |          |            |              |      |   |         |
| Cont    |   |          |            |              |      |   |         |
| racting |   |          |            |              |      |   |         |
| Of      |   |          |            |              |      |   |         |
| ficer's |   |          |            |              |      |   |         |
| d       |   |          |            |              |      |   |         |
| ecision |   |          |            |              |      |   |         |
+---------+---+----------+------------+--------------+------+---+---------+
| ## Ch   |   | The      |            |              |      |   |         |
| eck One |   | req      |            |              |      |   |         |
|         |   | uestor's |            |              |      |   |         |
|         |   | at       |            |              |      |   |         |
|         |   | tendance |            |              |      |   |         |
|         |   | is       |            |              |      |   |         |
|         |   | aut      |            |              |      |   |         |
|         |   | horized. |            |              |      |   |         |
|         |   | The      |            |              |      |   |         |
|         |   | req      |            |              |      |   |         |
|         |   | uestor's |            |              |      |   |         |
|         |   | at       |            |              |      |   |         |
|         |   | tendance |            |              |      |   |         |
|         |   | is NOT   |            |              |      |   |         |
|         |   | au       |            |              |      |   |         |
|         |   | thorized |            |              |      |   |         |
+---------+---+----------+------------+--------------+------+---+---------+
| 15\.    |   |          |            |              |      |   |         |
| Sup     |   |          |            |              |      |   |         |
| porting |   |          |            |              |      |   |         |
| Sta     |   |          |            |              |      |   |         |
| tements |   |          |            |              |      |   |         |
+---------+---+----------+------------+--------------+------+---+---------+
|         |   |          |            |              |      |   |         |
+---------+---+----------+------------+--------------+------+---+---------+
| 16\.    |   |          | 17\. Title |              |      | 1 |         |
| Si      |   |          |            |              |      | 8 |         |
| gnature |   |          |            |              |      | \ |         |
|         |   |          |            |              |      | . |         |
|         |   |          |            |              |      | D |         |
|         |   |          |            |              |      | a |         |
|         |   |          |            |              |      | t |         |
|         |   |          |            |              |      | e |         |
+---------+---+----------+------------+--------------+------+---+---------+
|         |   |          | C          |              |      |   |         |
|         |   |          | ontracting |              |      |   |         |
|         |   |          | Officer,   |              |      |   |         |
|         |   |          |            |              |      |   |         |
|         |   |          |            |              |      |   |         |
+---------+---+----------+------------+--------------+------+---+---------+

+-----------------------------+-----+----------------------------------+
| # RESOURCE CO               | *   |                                  |
| NSERVATION AND RECOVERY ACT | [EO |                                  |
|                             | 13  |                                  |
|                             | 101 |                                  |
|                             | Ann |                                  |
|                             | ual |                                  |
|                             | R   |                                  |
|                             | epo |                                  |
|                             | rt. |                                  |
|                             | S   |                                  |
|                             | ect |                                  |
|                             | ion |                                  |
|                             | 6   |                                  |
|                             | 002 |                                  |
|                             | of  |                                  |
|                             | R   |                                  |
|                             | CRA |                                  |
|                             | re  |                                  |
|                             | qui |                                  |
|                             | res |                                  |
|                             | O   |                                  |
|                             | FPP |                                  |
|                             | ]{. |                                  |
|                             | mar |                                  |
|                             | k}* |                                  |
|                             |     |                                  |
|                             | *   |                                  |
|                             | [to |                                  |
|                             | rep |                                  |
|                             | ort |                                  |
|                             | to  |                                  |
|                             | Co  |                                  |
|                             | ngr |                                  |
|                             | ess |                                  |
|                             | on  |                                  |
|                             | the |                                  |
|                             | a   |                                  |
|                             | cti |                                  |
|                             | ons |                                  |
|                             | ta  |                                  |
|                             | ken |                                  |
|                             | by  |                                  |
|                             | ag  |                                  |
|                             | enc |                                  |
|                             | ies |                                  |
|                             | to  |                                  |
|                             | ]{. |                                  |
|                             | mar |                                  |
|                             | k}* |                                  |
|                             |     |                                  |
|                             | *[  |                                  |
|                             | imp |                                  |
|                             | lem |                                  |
|                             | ent |                                  |
|                             | t   |                                  |
|                             | his |                                  |
|                             | st  |                                  |
|                             | atu |                                  |
|                             | te. |                                  |
|                             | EO  |                                  |
|                             | 13  |                                  |
|                             | 101 |                                  |
|                             | r   |                                  |
|                             | ein |                                  |
|                             | for |                                  |
|                             | ces |                                  |
|                             | af  |                                  |
|                             | fir |                                  |
|                             | mat |                                  |
|                             | ive |                                  |
|                             | ]{. |                                  |
|                             | mar |                                  |
|                             | k}* |                                  |
|                             |     |                                  |
|                             | *[  |                                  |
|                             | pro |                                  |
|                             | cur |                                  |
|                             | eme |                                  |
|                             | nt, |                                  |
|                             | wa  |                                  |
|                             | ste |                                  |
|                             | m   |                                  |
|                             | ini |                                  |
|                             | miz |                                  |
|                             | ati |                                  |
|                             | on, |                                  |
|                             | and |                                  |
|                             | rec |                                  |
|                             | ycl |                                  |
|                             | ing |                                  |
|                             | e   |                                  |
|                             | ffo |                                  |
|                             | rts |                                  |
|                             | and |                                  |
|                             | ]{. |                                  |
|                             | mar |                                  |
|                             | k}* |                                  |
|                             |     |                                  |
|                             | *   |                                  |
|                             | [re |                                  |
|                             | qui |                                  |
|                             | res |                                  |
|                             | F   |                                  |
|                             | ede |                                  |
|                             | ral |                                  |
|                             | ag  |                                  |
|                             | enc |                                  |
|                             | ies |                                  |
|                             | to  |                                  |
|                             | rep |                                  |
|                             | ort |                                  |
|                             | th  |                                  |
|                             | eir |                                  |
|                             | ef  |                                  |
|                             | for |                                  |
|                             | ts. |                                  |
|                             | ]{. |                                  |
|                             | mar |                                  |
|                             | k}* |                                  |
|                             |     |                                  |
|                             | []{ |                                  |
|                             | .ma |                                  |
|                             | rk} |                                  |
+-----------------------------+-----+----------------------------------+
| REGION/CENTER & OFFICE      |     | ***SEND TO:***                   |
| SYMBOL                      |     |                                  |
|                             |     | ***Federal Aviation              |
|                             |     | Administration***                |
|                             |     |                                  |
|                             |     | ***800 Independence Ave SW***    |
|                             |     |                                  |
|                             |     | ***ATTN: ASU-110, Procurement    |
|                             |     | Info & Svc***                    |
|                             |     |                                  |
|                             |     | ***Rm 437, Ms. Aileen C.         |
|                             |     | Stafford***                      |
|                             |     |                                  |
|                             |     | ***Washington, DC 20591***       |
|                             |     |                                  |
|                             |     | ***Email:                        |
|                             |     | <aileen.c.stafford@faa.gov>***   |
|                             |     |                                  |
|                             |     | ***Office: 202-267-9674 Fax:     |
|                             |     | 202-267-8401***                  |
+-----------------------------+-----+----------------------------------+
| NAME & TITLE OF REPORTING   |     |                                  |
| OFFICIAL                    |     |                                  |
+-----------------------------+-----+----------------------------------+
| OFFICE PHONE \#             |     |                                  |
+-----------------------------+-----+----------------------------------+
| FISCAL YEAR                 |     |                                  |
+-----------------------------+-----+----------------------------------+
| ### 1. EPA GUIDELINE ITEMS  |     |                                  |
+-----------------------------+-----+----------------------------------+
| A.  **Cement and Concrete   |     |                                  |
|     Products** containing   |     |                                  |
|     fly ash and cement and  |     |                                  |
|     concrete products       |     |                                  |
|     containing granulated   |     |                                  |
|     blast furnace slag      |     |                                  |
|     (slag).                 |     |                                  |
|                             |     |                                  |
| > 1\. Total amount of       |     |                                  |
| > **cement** purchased      |     |                                  |
| > and/or used by your       |     |                                  |
| > agency in FY200\_\_.      |     |                                  |
| >                           |     |                                  |
| > Without fly ash or slag   |     |                                  |
| > \$\_\_\_\_\_\_\_\_\_\_\_  |     |                                  |
| > and/or                    |     |                                  |
| > \_\_\_\_\_\_\_\_\_\_\_\_  |     |                                  |
| > cubic yards, and/or total |     |                                  |
| > number of contracts       |     |                                  |
| > awarded                   |     |                                  |
| > \_\_\_\_\_\_\_\_\_\_\_\_. |     |                                  |
|                             |     |                                  |
| With fly ash or slag        |     |                                  |
| \$\_\_\_\_\_\_\_\_\_\_\_\_  |     |                                  |
| and/or                      |     |                                  |
| \_                          |     |                                  |
| \_\_\_\_\_\_\_\_\_\_\_cubic |     |                                  |
| yards, and/or total number  |     |                                  |
| of contracts awarded        |     |                                  |
| \_\_\_\_\_\_\_\_\_\_.       |     |                                  |
|                             |     |                                  |
| > 2\. Total amount of       |     |                                  |
| > **concrete** purchased    |     |                                  |
| > and/or used by your       |     |                                  |
| > agency in FY200\_\_.      |     |                                  |
| >                           |     |                                  |
| > Without fly ash or slag   |     |                                  |
| > \$\_\_\_\_\_\_\_\_\_\_\_  |     |                                  |
| > and/or                    |     |                                  |
| > \_\_\_\_\_\_\_\_\_\_\_\_  |     |                                  |
| > cubic yards, and/or total |     |                                  |
| > number of contracts       |     |                                  |
| > awarded                   |     |                                  |
| > \_\_\_\_\_\_\_\_\_\_\_\_. |     |                                  |
|                             |     |                                  |
| With fly ash or slag        |     |                                  |
| \$\_\_\_\_\_\_\_\_\_\_\_\_  |     |                                  |
| and/or                      |     |                                  |
| \_                          |     |                                  |
| \_\_\_\_\_\_\_\_\_\_\_cubic |     |                                  |
| yards, and/or total number  |     |                                  |
| of contracts awarded        |     |                                  |
| \_\_\_\_\_\_\_\_\_\_\_\_.   |     |                                  |
|                             |     |                                  |
| 3.  Were there technical    |     |                                  |
|     impediments to          |     |                                  |
|     increasing the amount   |     |                                  |
|     of concrete and cement  |     |                                  |
|     containing fly ash and  |     |                                  |
|     granulated blast        |     |                                  |
|     furnace slag purchased  |     |                                  |
|     by your agency in       |     |                                  |
|     FY200\_\_? (If yes,     |     |                                  |
|     please attach an        |     |                                  |
|     explanation of the      |     |                                  |
|     technical impediment.)  |     |                                  |
|                             |     |                                  |
| > B. **Paper and Paper      |     |                                  |
| > Products**. GSA and GPO   |     |                                  |
| > will provide data for     |     |                                  |
| > agencies\' purchases of   |     |                                  |
| > paper products made       |     |                                  |
| > through their retail and  |     |                                  |
| > wholesale stock program.  |     |                                  |
| > However, please provide   |     |                                  |
| > amounts for agency        |     |                                  |
| > purchases from any other  |     |                                  |
| > sources.                  |     |                                  |
| >                           |     |                                  |
| > 1\. Total dollar amount   |     |                                  |
| > of paper and paper        |     |                                  |
| > products purchased ‑ by   |     |                                  |
| > your agency from sources  |     |                                  |
| > other than GSA and GPO in |     |                                  |
| > FY 200\_\_                |     |                                  |
| > \$\_\_\_\_\_\_\_\_\_.     |     |                                  |
|                             |     |                                  |
| 2.  Total dollar amount of  |     |                                  |
|     paper and paper         |     |                                  |
|     products [containing    |     |                                  |
|     recycled]{.underline}   |     |                                  |
|     material purchased by   |     |                                  |
|     your agency from        |     |                                  |
|     sources other than GSA  |     |                                  |
|     and GPO in FY 200\_\_   |     |                                  |
|     \$\_\_\_\_\_\_\_\_\_.   |     |                                  |
|                             |     |                                  |
| > C. **Motor Vehicle        |     |                                  |
| > Lubricating Oils. DLA     |     |                                  |
| > will provide data for     |     |                                  |
| > agencies\' purchases of   |     |                                  |
| > oil through their**       |     |                                  |
| >                           |     |                                  |
| > **program. However,       |     |                                  |
| > please provide amounts    |     |                                  |
| > for agency purchases from |     |                                  |
| > other sources.**          |     |                                  |
| >                           |     |                                  |
| > 1\. Total amount of motor |     |                                  |
| > vehicle lubricating oil   |     |                                  |
| > purchased by your agency  |     |                                  |
| > in FY 200\_\_             |     |                                  |
| > \$\_\_\_\_\_\_\_\_\_\_\_. |     |                                  |
| > (If your vehicle          |     |                                  |
| > maintenance is            |     |                                  |
| > accomplished through      |     |                                  |
| > service contracts that    |     |                                  |
| > include a standard        |     |                                  |
| > price‑for                 |     |                                  |
| >                           |     |                                  |
| > vehicle servicing, report |     |                                  |
| > the total number of       |     |                                  |
| > servicing(s) rather than  |     |                                  |
| > the dollar‑value.)        |     |                                  |
+-----------------------------+-----+----------------------------------+
| > 2\. Total dollar amount   |     |                                  |
| > of motor vehicle          |     |                                  |
| > lubricating oils          |     |                                  |
| > containing refined oil    |     |                                  |
| > purchased by your agency  |     |                                  |
| > in FY 200\_\_             |     |                                  |
| > \$\_\_\_\_\_\_\_\_\_\_.   |     |                                  |
| > (If your vehicle          |     |                                  |
| > maintenance is            |     |                                  |
| > accomplished through      |     |                                  |
| > service contracts that    |     |                                  |
| > include a standard price  |     |                                  |
| > for vehicle servicing,    |     |                                  |
| > report the total number   |     |                                  |
| > of services where the     |     |                                  |
| > vehicle was serviced with |     |                                  |
| > re‑refined oil rather     |     |                                  |
| > than the dollar value.)   |     |                                  |
| >                           |     |                                  |
| > 3\. Were there any        |     |                                  |
| > technical impediments to  |     |                                  |
| > increasing the amount of  |     |                                  |
| > motor vehicle lubricating |     |                                  |
| > oils containing           |     |                                  |
| > re‑refined oil purchased  |     |                                  |
| > by your agency in FY      |     |                                  |
| > 200\_\_? (If yes, please  |     |                                  |
| > attach an explanation of  |     |                                  |
| > the technical             |     |                                  |
| > impediment.)              |     |                                  |
| >                           |     |                                  |
| > D. **Retread Tires. Refer |     |                                  |
| > to the Federal Supply     |     |                                  |
| > Schedule for Pneumatic    |     |                                  |
| > Tires, FSC Group 26, Part |     |                                  |
| > II, Section A for items   |     |                                  |
| > covered by this           |     |                                  |
| > guideline.**              |     |                                  |
| >                           |     |                                  |
| > TACOM will provide data   |     |                                  |
| > for agencies\' purchases  |     |                                  |
| > of retreads for tactical  |     |                                  |
| > vehicles.                 |     |                                  |
| >                           |     |                                  |
| > 1\. Total dollar amount   |     |                                  |
| > of tires purchased by     |     |                                  |
| > your agency in FY 200\_\_ |     |                                  |
| >                           |     |                                  |
| \$\_\_\_\_\_\_\_\_\_\_\_\_. |     |                                  |
| >                           |     |                                  |
| > 2\. Total number of tires |     |                                  |
| > purchased by your agency  |     |                                  |
| > in FY 200\_\_             |     |                                  |
| >                           |     |                                  |
| \$\_\_\_\_\_\_\_\_\_\_\_\_. |     |                                  |
| >                           |     |                                  |
| > 3\. Total dollar amount   |     |                                  |
| > of [retread               |     |                                  |
| > tires]{.underline}        |     |                                  |
| > purchased by your agency  |     |                                  |
| > in FY 200\_\_             |     |                                  |
| > \$\_\_\_\_\_\_\_\_\_\_\_. |     |                                  |
| >                           |     |                                  |
| > 4\. Total number of       |     |                                  |
| > [retread                  |     |                                  |
| > tires]{.underline}        |     |                                  |
| > purchased by your agency  |     |                                  |
| > in FY 200\_\_             |     |                                  |
| > \$\_\_\_\_\_\_\_\_\_\_\_. |     |                                  |
| >                           |     |                                  |
| > 5\. Were there any        |     |                                  |
| > technical impediments to  |     |                                  |
| > increasing the amount of  |     |                                  |
| > retread tires purchased   |     |                                  |
| > by your agency in FY      |     |                                  |
| > 200\_\_                   |     |                                  |
| > \$\_\_\_\_\_\_\_\_\_\_\_  |     |                                  |
| > (if yes, please attach an |     |                                  |
| > explanation of the        |     |                                  |
| > technical impediment.)    |     |                                  |
| >                           |     |                                  |
| > E. **Building Insulation  |     |                                  |
| > Products.**               |     |                                  |
|                             |     |                                  |
| 1.  Total dollar amount of  |     |                                  |
|     building insulation     |     |                                  |
|     products purchased by   |     |                                  |
|     your agency in FY       |     |                                  |
|     200\_\_                 |     |                                  |
|     \$\_\_\_\_\_\_\_\_\_\_  |     |                                  |
|                             |     |                                  |
| > or total number of        |     |                                  |
| > contracts awarded         |     |                                  |
| > \_\_\_\_\_\_\_\_\_\_.     |     |                                  |
|                             |     |                                  |
| 2.  Total dollar value of   |     |                                  |
|     building insulation     |     |                                  |
|     products containing     |     |                                  |
|     recycled aerials        |     |                                  |
|     purchased by agency in  |     |                                  |
|     FY200\_\_?              |     |                                  |
|     \_\_\_\_\_\_\_\_\_\_\_  |     |                                  |
|     (If yes, please attach  |     |                                  |
|     an explanation of the   |     |                                  |
|     technical impediment.)  |     |                                  |
|                             |     |                                  |
| > 3\. Were there any        |     |                                  |
| > technical impediments to  |     |                                  |
| > increasing the amount of  |     |                                  |
| > building insulation       |     |                                  |
| > products containing       |     |                                  |
| > recycled materials        |     |                                  |
| > purchased by your agency  |     |                                  |
| > in FY 200\_\_? (If yes,   |     |                                  |
| > please attach an          |     |                                  |
| > explanation of the        |     |                                  |
| > technical impediment.)    |     |                                  |
| >                           |     |                                  |
| > F. **Engine Coolants.**   |     |                                  |
| >                           |     |                                  |
| > 1\. For agencies that     |     |                                  |
| > maintain fleet            |     |                                  |
| > maintenance facilities,   |     |                                  |
| > how many fleet            |     |                                  |
| > maintenance facilities do |     |                                  |
| > you operate?              |     |                                  |
| >                           |     |                                  |
| > 2\. How many vehicles are |     |                                  |
| > maintained?               |     |                                  |
| >                           |     |                                  |
| > 3\. How many of your      |     |                                  |
| > fleet maintenance         |     |                                  |
| > facilities own and        |     |                                  |
| > operate                   |     |                                  |
| > [anti­freeze]{.underline}  |     |                                  |
| > recycling equipment?      |     |                                  |
+-----------------------------+-----+----------------------------------+
| > G. **Structural           |     |                                  |
| > Fiberboard and Laminated  |     |                                  |
| > Paperboard.**             |     |                                  |
| >                           |     |                                  |
| > 1\. Total dollar amount   |     |                                  |
| > of structural fiberboard  |     |                                  |
| > and laminated paperboard  |     |                                  |
| > purchased by your agency  |     |                                  |
| > in FY 200\_\_ \$          |     |                                  |
| > \_\_\_\_\_\_\_\_\_ or     |     |                                  |
| > total number of contracts |     |                                  |
| > awarded                   |     |                                  |
| > \_\_\_\_\_\_\_\_\_\_\_.   |     |                                  |
| >                           |     |                                  |
| > 2\. Total dollar amount   |     |                                  |
| > of structural fiberboard  |     |                                  |
| > and, laminated paperboard |     |                                  |
| > [containing recycled      |     |                                  |
| > materials]{.underline}    |     |                                  |
| > purchased by your agency  |     |                                  |
| > in FY 200\_\_             |     |                                  |
| > \$\_\_\_\_\_\_\_\_\_\_ or |     |                                  |
| > total number of contracts |     |                                  |
| > awarded.                  |     |                                  |
| >                           |     |                                  |
| > 3\. there technical       |     |                                  |
| > impediments to increasing |     |                                  |
| > the amount of recycled    |     |                                  |
| > materials for structural  |     |                                  |
| >                           |     |                                  |
| > fiberboard and laminated  |     |                                  |
| > paperboard purchased by   |     |                                  |
| > your agency in FY200\_\_? |     |                                  |
| > \_\_\_\_\_\_\_\_\_ (If    |     |                                  |
| > yes, attach an            |     |                                  |
| > explanation of the        |     |                                  |
| > technical impediments.)   |     |                                  |
|                             |     |                                  |
| H.  **Carpet (low and       |     |                                  |
|     medium wear polyester   |     |                                  |
|     fiber only).**          |     |                                  |
|                             |     |                                  |
| > Provide any pertinent     |     |                                  |
| > information to            |     |                                  |
| > demonstrate your agency's |     |                                  |
| > compliance/commitment to  |     |                                  |
| > purchasing carpet (low    |     |                                  |
| > and medium wear polyester |     |                                  |
| > fiber) in FY 200\_\_.     |     |                                  |
| > This information could    |     |                                  |
| > include dollars spent,    |     |                                  |
| > number of contracts,      |     |                                  |
| > policies issued, pilot    |     |                                  |
| > projects, etc.            |     |                                  |
|                             |     |                                  |
| I.  **Floor Tiles (rubber   |     |                                  |
|     or plastic only)**      |     |                                  |
|                             |     |                                  |
| > Provide any pertinent     |     |                                  |
| > information to            |     |                                  |
| > demonstrate your agency's |     |                                  |
| > compliance/commitment to  |     |                                  |
| > purchasing floor tiles    |     |                                  |
| > (rubber or plastic only)  |     |                                  |
| > in FY 200\_\_. This       |     |                                  |
| > information could include |     |                                  |
| > dollars spent, number of  |     |                                  |
| > contracts, policies       |     |                                  |
| > issued, pilot projects,   |     |                                  |
| > etc.                      |     |                                  |
|                             |     |                                  |
| J.  **Traffic Cones and     |     |                                  |
|     Traffic Barricades      |     |                                  |
|     (rubber or plastic      |     |                                  |
|     only). GSA will provide |     |                                  |
|     data for agencies'      |     |                                  |
|     purchases of traffic    |     |                                  |
|     cones and traffic       |     |                                  |
|     barricades and those    |     |                                  |
|     with recycled           |     |                                  |
|     materials. However,     |     |                                  |
|     please provide amounts  |     |                                  |
|     for agencies' purchases |     |                                  |
|     from other sources.**   |     |                                  |
|                             |     |                                  |
| > Total dollar amount of    |     |                                  |
| > traffic cones and traffic |     |                                  |
| > barricades purchased by   |     |                                  |
| > your agency in FY 200\_\_ |     |                                  |
| >                           |     |                                  |
| > \$\_\_\_\_\_\_\_\_.       |     |                                  |
| >                           |     |                                  |
| > Total dollar amount of    |     |                                  |
| > traffic cones and traffic |     |                                  |
| > barricades [with recycled |     |                                  |
| > content]{.underline}      |     |                                  |
| > purchased by your agency  |     |                                  |
| > in FY 200\_\_             |     |                                  |
| > \_\_\_\_\_\_\_\_\_\_\_.   |     |                                  |
|                             |     |                                  |
| K.  **Office Recycling and  |     |                                  |
|     Waste Containers        |     |                                  |
|     (plastics, paper or     |     |                                  |
|     steel)**                |     |                                  |
|                             |     |                                  |
| > Provide any pertinent     |     |                                  |
| > information to            |     |                                  |
| > demonstrate your agency's |     |                                  |
| > compliance/commitment to  |     |                                  |
| > purchasing office         |     |                                  |
| > recycling and waste       |     |                                  |
| > containers (plastic,      |     |                                  |
| > paper or steel) in FY     |     |                                  |
| > 200\_\_. This information |     |                                  |
| > could include dollars     |     |                                  |
| > spent, number of          |     |                                  |
| > contracts, policies       |     |                                  |
| > issued, pilot projects,   |     |                                  |
| > etc.                      |     |                                  |
|                             |     |                                  |
| L.  **Plastic Desktop       |     |                                  |
|     Accessories. GSA will   |     |                                  |
|     provide data for        |     |                                  |
|     agencies' purchases of  |     |                                  |
|     desktop accessories and |     |                                  |
|     plastic desktop         |     |                                  |
|     accessories. However,   |     |                                  |
|     please provide amounts  |     |                                  |
|     for agency purchases    |     |                                  |
|     from any other          |     |                                  |
|     source.**               |     |                                  |
|                             |     |                                  |
| > 1\. Total dollar amount   |     |                                  |
| > of desktop accessories    |     |                                  |
| > purchased by your agency  |     |                                  |
| > in FY 200\_\_             |     |                                  |
| > \$                        |     |                                  |
| \_\_\_\_\_\_\_\_\_\_\_\_\_. |     |                                  |
| >                           |     |                                  |
| > 2\. Total dollar amount   |     |                                  |
| > of recycled content       |     |                                  |
| > plastic desktop           |     |                                  |
| > accessories purchased by  |     |                                  |
| > your agency in FY 200\_\_ |     |                                  |
| > \$\_                      |     |                                  |
| \_\_\_\_\_\_\_\_\_\_\_\_\_. |     |                                  |
+-----------------------------+-----+----------------------------------+
| M.  **Toner Cartridges. GSA |     |                                  |
|     and DLA will provide    |     |                                  |
|     data for agencies'      |     |                                  |
|     purchases of toner      |     |                                  |
|     cartridges and recycled |     |                                  |
|     toner cartridges.       |     |                                  |
|     However, please provide |     |                                  |
|     amounts for agency      |     |                                  |
|     purchases from other    |     |                                  |
|     sources.**              |     |                                  |
|                             |     |                                  |
| 1\. Total dollar amount of  |     |                                  |
| toner cartridges purchased  |     |                                  |
| by your agency in FY        |     |                                  |
| 200\_\_                     |     |                                  |
| \$\_\_\_\_\_\_\_\_\_\_.     |     |                                  |
|                             |     |                                  |
| > 2\. Total dollar amount   |     |                                  |
| > of [recycled]{.underline} |     |                                  |
| > toner cartridges          |     |                                  |
| > purchased by your agency  |     |                                  |
| > in FY 200\_\_             |     |                                  |
| > \$\_\_\_\_\_\_\_\_\_.     |     |                                  |
|                             |     |                                  |
| N.  **Binders (chipboard    |     |                                  |
|     and plastic covered,    |     |                                  |
|     not cloth). GSA and DLA |     |                                  |
|     will provide data for   |     |                                  |
|     agencies' purchases of  |     |                                  |
|     binders and chipboard   |     |                                  |
|     and plastic covered     |     |                                  |
|     binders. However,       |     |                                  |
|     please provide amounts  |     |                                  |
|     for agency purchases    |     |                                  |
|     from other sources.**   |     |                                  |
|                             |     |                                  |
| 1\. Total dollar amount of  |     |                                  |
| binders purchased by your   |     |                                  |
| agency in FY 200\_\_        |     |                                  |
| \$\_\_\_\_\_\_\_\_\_\_.     |     |                                  |
|                             |     |                                  |
| > 2\. Total dollar amount   |     |                                  |
| > of [recycled]{.underline} |     |                                  |
| > content chipboard and     |     |                                  |
| > plastic covered binders   |     |                                  |
| > in FY 200\_\_             |     |                                  |
| > \$\_\_\_\_\_\_\_\_\_.     |     |                                  |
|                             |     |                                  |
| O.  **Plastic Trash Bags**  |     |                                  |
|                             |     |                                  |
| > II\. Specifications.      |     |                                  |
| > RCRA, Section 6002 (d)    |     |                                  |
| > requires that Federal     |     |                                  |
| > activities that have      |     |                                  |
| > responsibility for        |     |                                  |
| > preparing specifications: |     |                                  |
| > review them to eliminate  |     |                                  |
| > unnecessary requirements  |     |                                  |
| > for the use of virgin     |     |                                  |
| > materials and             |     |                                  |
| > prohibitions against      |     |                                  |
| > using recovered           |     |                                  |
| > materials; and add        |     |                                  |
| > preferences for recovered |     |                                  |
| > materials.                |     |                                  |
|                             |     |                                  |
| A.  Does your agency have   |     |                                  |
|     responsibility of       |     |                                  |
|     control over a          |     |                                  |
|     particular Federal      |     |                                  |
|     supply class or group   |     |                                  |
|     of specifications or    |     |                                  |
|     standards?              |     |                                  |
|     Yes\_\_\_\_\_\_\_\_\_\_ |     |                                  |
|     No\_\_\_\_\_\_\_\_\_\_. |     |                                  |
|                             |     |                                  |
| B.  How many product        |     |                                  |
|     specification,          |     |                                  |
|     standards, commercial   |     |                                  |
|     item descriptions       |     |                                  |
|     (CIDs), product         |     |                                  |
|     description or similar  |     |                                  |
|     documents does your     |     |                                  |
|     agency control? Number  |     |                                  |
|     \_\_\_\_\_\_\_\_\_\_\_. |     |                                  |
|                             |     |                                  |
| C.  How many documents were |     |                                  |
|     modified in FY 200\_\_  |     |                                  |
|     to remove the           |     |                                  |
|     requirements for the    |     |                                  |
|     use of virgin           |     |                                  |
|     materials?              |     |                                  |
|                             |     |                                  |
| Number\_\_\_\_\_\_\_\_\_\_. |     |                                  |
|                             |     |                                  |
| D.  How many documents were |     |                                  |
|     modified in FY 200\_\_  |     |                                  |
|     to remove the           |     |                                  |
|     requirements for the    |     |                                  |
|     use of virgin           |     |                                  |
|     materials? Number       |     |                                  |
|     \_\_\_\_\_\_\_\_\_.     |     |                                  |
|                             |     |                                  |
| E.  How many documents were |     |                                  |
|     modified in FY200\_\_   |     |                                  |
|     to remove references of |     |                                  |
|     language prohibiting    |     |                                  |
|     the use of recovered    |     |                                  |
|     materials?              |     |                                  |
|                             |     |                                  |
|   Number\_\_\_\_\_\_\_\_\_. |     |                                  |
|                             |     |                                  |
| F.  How many documents were |     |                                  |
|     modified in FY200\_\_   |     |                                  |
|     to add preferences for  |     |                                  |
|     recovered materials?    |     |                                  |
|     Number                  |     |                                  |
|     \_\_\_\_\_\_\_\_\_.     |     |                                  |
|                             |     |                                  |
| G.  Does your agency have a |     |                                  |
|     policy to remove the    |     |                                  |
|     requirements for virgin |     |                                  |
|     materials and add       |     |                                  |
|     preferences for         |     |                                  |
|     recovered materials to  |     |                                  |
|     these service           |     |                                  |
|     contracts? (i.e.        |     |                                  |
|     including the use of    |     |                                  |
|     re-refined oil in your  |     |                                  |
|     vehicle service         |     |                                  |
|     contracts).             |     |                                  |
|     Yes\_\_\_\_\_\_\_\_\_   |     |                                  |
|     No\_\_\_\_\_\_\_\_      |     |                                  |
|                             |     |                                  |
| H.  If your agency does     |     |                                  |
|     have a policy like the  |     |                                  |
|     above, please provide a |     |                                  |
|     copy to us.             |     |                                  |
|                             |     |                                  |
| I.  If your agency does not |     |                                  |
|     have a policy, please   |     |                                  |
|     provide an explanation. |     |                                  |
|                             |     |                                  |
|     III.                    |     |                                  |
|                             |     |                                  |
|     IV. **III. Solid Waste  |     |                                  |
|         Prevention**        |     |                                  |
|                             |     |                                  |
|     V.                      |     |                                  |
|                             |     |                                  |
| Please report solid waste   |     |                                  |
| prevention efforts for      |     |                                  |
| facilities for which your   |     |                                  |
| agency is responsible.      |     |                                  |
|                             |     |                                  |
| A.  Did you institute new   |     |                                  |
|     solid waste prevention  |     |                                  |
|     practices in FY 2001?   |     |                                  |
|     Yes\_\_\_\_\_\_\_\_     |     |                                  |
|     No\_\_\_\_\_\_\_\_      |     |                                  |
|                             |     |                                  |
| B.  If the response is Yes, |     |                                  |
|     please provide an       |     |                                  |
|     explanation of those    |     |                                  |
|     practices.              |     |                                  |
|                             |     |                                  |
| C.  If the response is No,  |     |                                  |
|     please provide an       |     |                                  |
|     explanation of why not. |     |                                  |
|                             |     |                                  |
| **IV. Recycling**           |     |                                  |
|                             |     |                                  |
| A.  What percentage of the  |     |                                  |
|     offices/sites operated  |     |                                  |
|     by your agency have an  |     |                                  |
|     active office products  |     |                                  |
|     recycling program?      |     |                                  |
|     \_\_\_\_\_\_ % Percent  |     |                                  |
|                             |     |                                  |
| B.  What percentage of      |     |                                  |
|     residential housing     |     |                                  |
|     operated by your agency |     |                                  |
|     have an active          |     |                                  |
|     household products      |     |                                  |
|     recycling program?      |     |                                  |
|     \_\_\_\_\_\_% Percent   |     |                                  |
|                             |     |                                  |
| C.  What percentage of      |     |                                  |
|     demolition projects     |     |                                  |
|     managed by and/or       |     |                                  |
|     contracted by your      |     |                                  |
|     agency includes the     |     |                                  |
|     recovery of             |     |                                  |
|     construction materials? |     |                                  |
|     \_\_\_\_\_\_% Percent   |     |                                  |
|                             |     |                                  |
| D.  What percentage of your |     |                                  |
|     total solid waste was   |     |                                  |
|     diverted to recycling?  |     |                                  |
|     \_\_\_\_\_\_% Percent   |     |                                  |
|                             |     |                                  |
| **V. Miscellaneous**        |     |                                  |
|                             |     |                                  |
| A.  Has your agency         |     |                                  |
|     established an internal |     |                                  |
|     awards program per the  |     |                                  |
|     requirements of         |     |                                  |
|     Executive Order (E.O.)  |     |                                  |
|     13101?                  |     |                                  |
|     Yes\_\_\_\_\_\_\_\_     |     |                                  |
|     No\_\_\_\_\_\_\_\_\_    |     |                                  |
|                             |     |                                  |
| > If the response is Yes,   |     |                                  |
| > provide a description of  |     |                                  |
| > the awards program.       |     |                                  |
| >                           |     |                                  |
| > If the response is No,    |     |                                  |
| > provide an explanation of |     |                                  |
| > why an internal awards    |     |                                  |
| > programs has not been     |     |                                  |
| > established.              |     |                                  |
|                             |     |                                  |
| B.  Has your agency         |     |                                  |
|     established guidance    |     |                                  |
|     for your credit card    |     |                                  |
|     holders on E.O. 13101   |     |                                  |
|     per the requirements of |     |                                  |
|     the E.O.?               |     |                                  |
|     Yes\_\_\_\_\_\_\_\_\_   |     |                                  |
|     No \_\_\_\_\_\_\_\_\_   |     |                                  |
|                             |     |                                  |
| If the response is Yes,     |     |                                  |
| provide a description of    |     |                                  |
| the credit card guidance.   |     |                                  |
|                             |     |                                  |
| > If the response is No,    |     |                                  |
| > provide an explanation of |     |                                  |
| > why there is no agency    |     |                                  |
| > credit card training on   |     |                                  |
| > E.O. 13101 and green      |     |                                  |
| > purchasing.               |     |                                  |
|                             |     |                                  |
| C.  Did your agency         |     |                                  |
|     participate in an       |     |                                  |
|     Environmentally         |     |                                  |
|     Preferable Products and |     |                                  |
|     Services (EPP) pilot    |     |                                  |
|     project per the         |     |                                  |
|     requirements of         |     |                                  |
|     E.O. 13101.             |     |                                  |
|     Yes\_\_\_\_\_\_\_\_     |     |                                  |
|     No\_\_\_\_\_\_\_\_\_\_  |     |                                  |
|                             |     |                                  |
| If the response Yes,        |     |                                  |
| provide information of the  |     |                                  |
| number, description, and    |     |                                  |
| status of the EPP pilots.   |     |                                  |
|                             |     |                                  |
| > If the response is No,    |     |                                  |
| > provide an explanation of |     |                                  |
| > why your agency has not   |     |                                  |
| > participated in an EPP    |     |                                  |
| > pilot project per the     |     |                                  |
| > requirement of E.O.       |     |                                  |
| > 13101.                    |     |                                  |
| >                           |     |                                  |
| > OMB Control No. 2120-0595 |     |                                  |
| > OST Interagency Report    |     |                                  |
+-----------------------------+-----+----------------------------------+

<table>
<colgroup>
<col style="width: 31%" />
<col style="width: 4%" />
<col style="width: 10%" />
<col style="width: 7%" />
<col style="width: 5%" />
<col style="width: 3%" />
<col style="width: 2%" />
<col style="width: 1%" />
<col style="width: 3%" />
<col style="width: 5%" />
<col style="width: 3%" />
<col style="width: 0%" />
<col style="width: 7%" />
<col style="width: 0%" />
<col style="width: 1%" />
<col style="width: 11%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="9"><strong>SUBCONTRACTING REPORT FOR INDIVIDUAL
CONTRACTS<br />
<em>(See instructions on reverse)</em></strong></td>
<td colspan="7">OMB No.: <strong>2120-0595</strong></td>
</tr>
<tr class="even">
<td colspan="16">Public reporting burden for this collection of
information is estimated to average 8 hours per response, including the
time for reviewing instructions, searching existing data sources,
gathering and maintaining the data needed, and completing and reviewing
the collection of information. Send comments regarding this burden
estimate or any other aspect of this collection of information,
including suggestions for reducing this burden, to the FAR Secretariat
(MVR), Federal Acquisition Policy Division, GSA, Washington, DC
20405.</td>
</tr>
<tr class="odd">
<td colspan="6">1. CORPORATION, COMPANY OR SUBDIVISION COVERED</td>
<td colspan="10">3. DATE SUBMITTED</td>
</tr>
<tr class="even">
<td colspan="6">a. COMPANY NAME<br />
     </td>
<td colspan="10">     </td>
</tr>
<tr class="odd">
<td colspan="6" rowspan="2">b. STREET ADDRESS<br />
     </td>
<td colspan="10">4. REPORTING PERIOD FROM INCEPTION OF CONTRACT
THRU:</td>
</tr>
<tr class="even">
<td colspan="7" rowspan="2"> MAR 31 SEPT 30</td>
<td colspan="3" rowspan="2">YEAR<br />
<br />
     </td>
</tr>
<tr class="odd">
<td colspan="2">c. CITY<br />
     </td>
<td>d. STATE<br />
     </td>
<td colspan="3">e. ZIP CODE<br />
     </td>
</tr>
<tr class="even">
<td colspan="6" rowspan="2">2. CONTRACTOR IDENTIFICATION NUMBER<br />
     </td>
<td colspan="10">5. TYPE OF REPORT</td>
</tr>
<tr class="odd">
<td colspan="10"> REGULAR FINAL REVISED</td>
</tr>
<tr class="even">
<td colspan="16">6. ADMINISTERING ACTIVITY <em>(Please check applicable
box)</em></td>
</tr>
<tr class="odd">
<td><p> ARMY</p>
<p> NAVY</p>
<p> AIR FORCE</p></td>
<td colspan="5"><p> GSA</p>
<p> DOE</p>
<p> DEFENSE LOGISTICS AGENCY</p></td>
<td colspan="10"><p> NASA</p>
<p> OTHER FEDERAL AGENCY <em>(Specify)<br />
     </em></p></td>
</tr>
<tr class="even">
<td colspan="5">7. REPORT SUBMITTED AS <em>(Check one and provide
appropriate number)</em></td>
<td colspan="11">8. AGENCY OR CONTRACTOR AWARDING CONTRACT</td>
</tr>
<tr class="odd">
<td colspan="2" rowspan="2"><p> PRIME CONTRACTOR</p>
<p> SUBCONTRACTOR</p></td>
<td colspan="3"><p>PRIME CONTRACT NUMBER</p>
<p>     </p></td>
<td colspan="11"><p>a. AGENCY’S OR CONTRACTOR’S NAME</p>
<p>     </p></td>
</tr>
<tr class="even">
<td colspan="3"><p>SUBCONTRACT NUMBER</p>
<p>     </p></td>
<td colspan="11"><p>b. STREET ADDRESS</p>
<p>     </p></td>
</tr>
<tr class="odd">
<td colspan="5"><p>9. DOLLARS AND PERCENTAGES IN THE FOLLOWING
BLOCKS:</p>
<p> DO INCLUDE INDIRECT COSTS DO NOT INCLUDE INDIRECT COSTS</p></td>
<td colspan="7"><p>c. CITY</p>
<p>     </p></td>
<td colspan="3"><p>d. STATE</p>
<p>     </p></td>
<td><p>e. ZIP CODE</p>
<p>     </p></td>
</tr>
<tr class="even">
<td colspan="16"><strong>SUBCONTRACT AWARDS</strong></td>
</tr>
<tr class="odd">
<td colspan="4" rowspan="2">TYPE</td>
<td colspan="6">CURRENT GOAL</td>
<td colspan="6">ACTUAL CUMULATIVE</td>
</tr>
<tr class="even">
<td colspan="3">WHOLE DOLLARS</td>
<td colspan="3">PERCENT</td>
<td colspan="4">WHOLE DOLLARS</td>
<td colspan="2">PERCENT</td>
</tr>
<tr class="odd">
<td colspan="4"><p>10a. SMALL BUSINESS CONCERNS (include SDB,
WOSB,<br />
HBCU/MI, HUBZone SB, VOSB and Service-Disabled</p>
<p>VOSB ) <em>(Dollar Amount and Percent of 10c.)</em></p></td>
<td colspan="3">     </td>
<td colspan="3">     </td>
<td colspan="4">     </td>
<td colspan="2">     </td>
</tr>
<tr class="even">
<td colspan="4"><p>10b. LARGE BUSINESS CONCERNS <em>(Dollar Amount
and</em></p>
<p><em>Percent of 10c.)</em></p></td>
<td colspan="3">     </td>
<td colspan="3"></td>
<td colspan="4">     </td>
<td colspan="2">     </td>
</tr>
<tr class="odd">
<td colspan="4">10c. TOTAL <em>(Sum of 10a and 10b.)</em></td>
<td colspan="3">0</td>
<td colspan="3">100.0%</td>
<td colspan="4">0</td>
<td colspan="2">100.0%</td>
</tr>
<tr class="even">
<td colspan="4">11. SMALL DISADVANTAGED (SDB) CONCERNS
<em>(Include<br />
HBCU/MI) (Dollar Amount and Percent of 10c.)</em></td>
<td colspan="3">     </td>
<td colspan="3">     </td>
<td colspan="4">     </td>
<td colspan="2">     </td>
</tr>
<tr class="odd">
<td colspan="4">12. WOMEN-OWNED SMALL BUSINESS (WOSB) CONCERNS<br />
<em>(Dollar Amount and Percent of 10c.)</em></td>
<td colspan="3">     </td>
<td colspan="3">     </td>
<td colspan="4">     </td>
<td colspan="2">     </td>
</tr>
<tr class="even">
<td colspan="4">13. HISTORICALLY BLACK COLLEGES AND UNIVERSITIES<br />
(HBCU) AND MINORITY INSTITUTIONS (MI) <em>(If applicable)<br />
(Dollar Amount and Percent of 10c.)</em></td>
<td colspan="3">     </td>
<td colspan="3">     </td>
<td colspan="4">     </td>
<td colspan="2">     </td>
</tr>
<tr class="odd">
<td colspan="4">14. HUBZONE SMALL BUSINESS (HUBZone SB) CONCERNS<br />
<em>(Dollar Amount and Percent of 10c.)</em></td>
<td colspan="3">     </td>
<td colspan="3">     </td>
<td colspan="4">     </td>
<td colspan="2">     </td>
</tr>
<tr class="even">
<td colspan="4"><p>15. VETERAN-OWNED SMALL BUSINESS <em>(Include
Service-</em></p>
<p><em>Disabled Veteran-Owned SB)</em> <em>(Dollar Amount and
Percent</em></p>
<p><em>of 10c.)</em></p></td>
<td colspan="3">     </td>
<td colspan="3">     </td>
<td colspan="4">     </td>
<td colspan="2">     </td>
</tr>
<tr class="odd">
<td colspan="4">16. SERVICE-DISABLED VETERAN-OWNED SMALL BUSINESS
<em>(Dollar Amount and Percent of 10c.)</em>.</td>
<td colspan="3">     </td>
<td colspan="3">     </td>
<td colspan="4">     </td>
<td colspan="2">     </td>
</tr>
<tr class="even">
<td colspan="16"><p>17. REMARKS</p>
<p>     </p></td>
</tr>
<tr class="odd">
<td colspan="8" rowspan="2"><p>18a. NAME OF INDIVIDUAL ADMINISTERING
SUBCONTRACTING PLAN</p>
<blockquote>
<p>     </p>
</blockquote></td>
<td colspan="8">18b. TELEPHONE NUMBER</td>
</tr>
<tr class="even">
<td colspan="3"><p>AREA CODE</p>
<blockquote>
<p>     </p>
</blockquote></td>
<td colspan="5"><p>NUMBER</p>
<blockquote>
<p>     </p>
</blockquote></td>
</tr>
</tbody>
</table>

AUTHORIZED FOR LOCAL REPRODUCTION **STANDARD FORM 294** (REV. 10-2001)

Previous edition is not usable Prescribed by GSA-FAR (48 CFR) 53.219(a)