**PART 553 FORMS**

**SUBPART 553.1 GENERAL**

**553.101 Requirements for use of forms.**

Parts 501-552 and 570 prescribe the requirements for use of GSA forms
illustrated or referenced in this part. You may identify the
prescription as follows:

\(a\) [Forms available on-line]{.underline}. The list of forms available
on-line in 553.370-1 identifies the basic prescription for each
referenced form.

\(b\) [Illustrated forms]{.underline}. The prescription for each
illustrated form is identified by a cross-reference shown on the
illustration. When a form is mentioned in more than one place in this
regulation, the section referenced on the illustration is the section
that contains the basic prescription.

**553.102 Current editions.**

You must use the current edition of the forms identified in Subpart
553.3 unless otherwise authorized under this regulation.

**553.170 Establishing and revising GSA Forms.**

\(a\) If two or more GSA Services or Offices use a GSA form, the Office
of Acquisition Policy maintains the form.

\(b\) If only one GSA Service or Office uses a GSA form or if the form
is used for a contract type unique to one Service or Office (e.g.,
construction contracts), that Service or Office is responsible for
maintaining the form.

\(c\) Any proposed new or revised GSA acquisition related form must be
submitted to the Office of Acquisition Policy for review and
concurrence.

**SUBPART 553.3 ILLUSTRATIONS OF FORMS**

**553.300 Scope of subpart.**

This subpart illustrates standard and GSA forms prescribed or referenced
in Parts 501-551 and 570. Instructions on completing a form, if
included, are identified by the suffix \"I\" after the GSAR section
number.

GSAM\
APD 2800.12B, 09-01-99 H-137

**553.300-70 Forms not illustrated.**

This subpart does not illustrate either:

\(a\) Standard forms illustrated in the FAR.

\(b\) Forms available on-line. You can access the forms listed below at
the location indicated.

  ------------------ ------------ --------------------------- -----------------------------------------------
  **Reference**      **Form No.** **Title**                   **On-line Location**

  570.701            Standard     U.S. Government Lease for   http://www.gsa.gov/pbs/pe/stancla/stancla.htm
                     Form 2       Real Property               

  552.238-74         GSA Form 72A Contractor\'s Report of     http://vsc.gsa.gov
                                  Sales                       

  570.702(b)         GSA Form 276 Supplemental Lease          http://www.gsa.gov/forms
                                  Agreement                   

  513.302-70(b)      GSA Form 300 Order for Supplies and      http://www.gsa.gov/forms
                                  Services                    

  513.302-70(b)(2)   GSA Form     Order for Supplies and      http://www.gsa.gov/forms
                     300A         Services (Continuation)     

  509.106-2          GSA Form 353 Performance Evaluation &    http://www.gsa.gov/forms
                                  Facilities Report           

  509.105-1(a)       GSA Form 527 Contractor\'s               http://www.gsa.gov/forms
                                  Qualifications and          
                                  Financial Information       

  532.905-71(a)      GSA Form     Release of Claims           http://www.gsa.gov/forms
                     1142                                     

  570.702(c)         GSA Form     Proposal to Lease Space     http://www.gsa.gov/forms
                     1364                                     

  514.407-72         GSA Form     Recommendation for Award(s) http://www.gsa.gov/forms
                     1535                                     

  513.106(c)(2)      GSA Form     Small Purchase Tabulation   http://www.gsa.gov/forms
                     2010         Source List/Abstract        

  532.905-70         GSA Form     Certification of Progress   http://www.gsa.gov/forms
                     2419         Payments Under Fixed-Price  
                                  Construction Contracts      

  501.603-3(b)(1)    GSA Form     Personal Qualifications     http://www.gsa.gov/forms
                     3409         Statement for Appointment   
                                  as Contracting Officer      

  504.803(b)         GSA Form     Contract/Modification File  http://www.gsa.gov/forms
                     3420         Checklist File Format       
                                  (Award)                     

  503.104-5          GSA Form     Record of Authorization of  http://www.gsa.gov/forms
                     3617         Access to Proprietary or    
                                  Source Selection            
                                  Information                 

  570.702(a)         GSA Form     U.S. Government Lease for   http://www.gsa.gov/pbs/pe/stancla/stancla.htm
                     3626         Real Property (Short Form)  
  ------------------ ------------ --------------------------- -----------------------------------------------

(Next page is H-141) GSAM\
H-138 APD 2800.12B, CHGE 1, 10-1-99

**553.370-300-I Instructions for** **using the GSA Form 300, Order for
Supplies and Services.**

\[513.302-70(b)(2)\]

\(a\) [Completing the form]{.underline}.

[Block 1, Date of Orde]{.underline}r. Enter the date the order is signed
by the contracting/ordering officer.

[Block 2, Order Number]{.underline}. If an order is being placed against
an established contract, assign an order number in accordance with the
procedures in GSAR 504.7001-3. This block does not apply to open market
purchases/contracts.

[Block 3, Contract Number]{.underline}. If an order is being placed
against an established contract, insert the contract number of the
contract that the order is being placed against. If an open market
purchase/contract is involved, assign a contract number in accordance
with the procedures in GSAR 504.7001-2.

[Block 4, ACT Number]{.underline}. Assign an Accounting Control
Transaction (ACT) number in accordance with NEAR system procedures. If
the purchase is charged to the General Supply Fund (255X), contemplates
periodic billing or is for an amount that exceeds \$2,500, place the ACT
number label on copy 1, the \"paying office\" copy. The ACT number label
will be placed on the invoice for other purchases. NOTE: In some
organizations, the \"paying office\" copy is forwarded to a Budget or
Executive Office within the service or staff office where the ACT number
label is affixed to the copy and forwarded to the appropriate Finance
Division.

[Block 5, Accounting Classification]{.underline}. Enter the accounting
information in accordance with the procedures contained in the
Accounting Classification Handbook (COM P 4240.1). The following blocks
are mandatory and must be completed for each order: \"FUND,\" \"ORG
CODE,\" \"B/A CODE,\" \"O/C CODE,\" \"FUNC CODE,\" and \"C/E CODE.\" The
accounting information on modifications must be the same as the original
order, unless the accounting information is being modified.

[Block 6, Finance Division]{.underline}. To be completed by the Finance
Division.

[Block 7, To: Contractor]{.underline}. Enter the contractor\'s name and
address, including zip code.

[Block 8, Type of Order]{.underline}. Check \"block A\" when making an
open market purchase/contract and refer to the date of the contractor\'s
oral or written quotation in the space \"REFERENCE YOUR.\" Check \"block
B\" when placing orders against established contracts. Check \"block C\"
when using a GSA Form 300 to modify another GSA Form 300; enter the
modification number and the authority for issuing the change, i.e.,
\"changes\" clause or other authority for issuing. Assign modification
numbers in accordance with GSAR 504.7001-4.

GSAM\
APD 2800.12B, 09-01-99 H-141

**553.370-300-I Instructions for** **using the GSA Form 300, Order for
Supplies and Services.**

[Block 9, Taxpayer\'s Identification Number (TIN)]{.underline}. This
block is mandatory when making open market purchases of services from
firms or individuals that are not incorporated (partnerships or sole
proprietors). This requirement does not apply to supply
purchases/contracts. Obtain the firm\'s or individual\'s TIN and enter
it in \"block A.\" The Finance Division will return purchase orders if
block 9A is incomplete. If the contractor refuses to provide a TIN,
check \"block B\" to reduce payment by twenty percent. NOTE: The
contractor must be informed before checking \"block B\" that failure to
provide the TIN will result in twenty percent of the payment being
withheld.

[Block 10, Classification]{.underline}. Check the block in 10A that
indicates the classification of the contractor. Definitions of \"Small
Business,\" \"Disadvantaged Business,\" and \"Women-owned Business\" can
be found at FAR 19.001 and 52.219-3. Check the block in 10B that
indicates the type of business organization of the contractor. This
block is mandatory when making open market purchases of services.

[Block 11, Issuing Office]{.underline}. Enter the name, address,
including zip code, and telephone number of the office making the
purchase/contract.

[Block 12, Remittance Address]{.underline}. Ask the contractor for the
address that it would like the payment for the supplies or services to
be mailed. The Finance Division can only make payments to the address
indicated on the order. Therefore, in order for payments to be processed
in a timely manner, the contracting officer must ask the contractor for
a remittance address and enter it in \"block 12.\" If the contractor\'s
invoice requests payment to be made to a different address than the one
in block 12, the Finance Division will request the contracting officer
to modify the order within 5 days to provide the proper \"remit to\"
address. If the Finance Division does not receive a modification within
5 days, the invoice will be considered improper and will be returned to
the contractor.

[Block 13, Ship to]{.underline}. Enter the consignee address, including
zip code, and telephone number.

[Block 14, Place of Inspection and Acceptance]{.underline}. Enter the
location where inspection and acceptance will occur.

[Block 15, Requisition Office]{.underline}. Enter the name,
correspondence symbol and telephone number of the office that requested
the supplies or services be purchased.

[Block 16, F.O.B. Point]{.underline}. Enter the appropriate f.o.b.
point. See FAR 47.302 and 47.303 and GSAR 547.300.

[Block 17, Government B/L No]{.underline}. When supplies are shipped
using a Government Bill of Lading (GBL), enter the GBL number.

[Block 18, Delivery f.o.b. point on or before]{.underline}. Enter the
date when supplies or services are to be delivered. Terms such as
\"ASAP\" are unacceptable.

GSAM\
H-142 APD 2800.12B, 09-01-99

**553.370-300-I Instructions for** **using the GSA Form 300, Order for
Supplies and Services.**

[Block 19, Payment/Discount Terms]{.underline}. Enter the prompt payment
discount terms provided for in the contract when placing an order
against an established contract or the discount terms offered if
purchasing on the open market.

[Block 20, Schedule]{.underline}. Enter a complete description of the
supplies or services being procured, including quantity, unit price,
total price and any periodic billing requirements. In addition, the
estimated freight charges must be included when f.o.b. origin terms are
used and a Government Bill of Lading (GBL) is not issued.

Periods for inspection and acceptance of contract deliverables or
completed work that are different from the 5 days cited in the Prompt
Payment clause on the reverse of the GSA Form 300, must be included in
this block.

When a GSA Form 300 is used to modify another GSA Form 300, block 20
must describe in detail what is being modified, e.g., number of units
from \_\_\_ to \_\_\_, delivery date from \_\_\_ to \_\_\_ , etc.
Indicate the impact of the modification on the total price, e.g., total
price is increased from \$\_\_\_\_\_ to \$\_\_\_\_\_, total price is
decreased from \$\_\_\_\_\_ to \$\_\_\_\_\_, or the price of the
original order is unchanged.

[Block 21, Receiving Office]{.underline}. Enter the name, correspondence
symbol and telephone number of the office responsible for completing the
receiving report.

[Block 22, Shipping Point]{.underline}. When the Government is paying
the transportation cost or reimbursing the contractor for transportation
cost, enter the shipping point for the supplies being purchased. This
information should be obtained from the seller.

[Block 23, Gross Shipping Weight]{.underline}. When the Government is
paying the transportation cost or reimbursing the contractor for
transportation cost, enter the shipping weight for the supplies being
purchased. This information can usually be obtained from the seller.

[Block 24, Mail Invoice to]{.underline}. Enter the address of the
issuing office (same as block 11) or other designated program office
within the service or region for purchases which do not exceed \$2,500
except for procurements charged to the General Supply Fund (255X) and
procurements that anticipate periodic billings, e.g., utility contracts,
recurring building service contracts, equipment rentals, etc. For all
other purchases, enter the address of the appropriate Finance Division.
Enter the \"Fund\" in designated area.

[Block 25]{.underline}. If block 24 provides for the invoice to be
submitted directly to the appropriate Finance Division, enter the Chief,
Accounts Payable Branch in block A and his/her telephone number,
including area code, in block B. If block 24 provides for the invoice to
be submitted to the issuing office or other designated program office
within the service or region, enter the name and telephone number,
including area code, of an individual in that office.

GSAM\
APD 2800.12B, 09-01-99\` H-143

**553.370-300-I Instructions for** **using the GSA Form 300, Order for
Supplies and Services.**

[Block 26]{.underline}. Enter the name of the contracting/ordering
officer in block A and his/her telephone number, including area code, in
block B. The name of the contracting/ordering officer typed in block A
must correspond with the signature in block C. Obligating documents
cannot be signed for a contracting/ordering officer.

\(b\) [Distribution]{.underline}.

\(1\) The distribution for orders (GSA Form 300) that do not exceed
S2,500, except those orders charged to the General Supply Fund (255X) or
those which anticipate periodic billing, will be as follows:

Copy 1 - Paying Office (Original) - Retain in the contract file or send
to the program office within the service or region responsible for
preparing the receiving report (Copy 6). DO NOT send to the paying
office until the invoice is received and approved for payment.

Copy 2 - Contractor\'s original

Copy 3 - Purchase File (Contracting/Ordering Officer)

Copy 4 - Purchase Office (Distribution as necessary)

Copy 5 - Consignee

Copy 6 - Receiving Report (Paying Office)

Copy 7 - Memorandum (Distribution as necessary)

\(2\) The distribution for orders (GSA Form 300) that exceed \$2,500, is
charged to the General Supply Fund (255X), or that anticipates periodic
billing will be as follows:

Copy 1 - Paying Office (Original)

Copy 2 - Contractor\'s Original

Copy 3 - Purchase File (Contracting/Ordering Officer)

Copy 4 - Purchase Office (Distribution as necessary)

Copy 5 - Consignee

Copy 6 - Receiving Report (Paying Office) - Not applicable to State
A.I.D. overseas orders.

Copy 7 - Memorandum (Distribution as necessary)

GSAM\
H-144 APD 2800.12B, 09-01-99

**553.370-300-I Instructions for** **using the GSA Form 300, Order for
Supplies and Services.**

\(c\) [Certifying receipt and processing payments for procurements
requiring a written purchase order (GSA Form 300)]{.underline}

\(1\) When supplies or services are received, the contracting/ordering
office or designated program office will certify receipt and acceptance
and indicate the amount approved for payment on copy 6, Receiving
Report, of the GSA Form 300 or 300-1. When multiple deliveries/payments
are required, additional copies of the receiving report (copy 6) may be
reproduced or the GSA Form 3025 or 3025A, Receiving Report, used to
certify receipt and acceptance. Photocopied signatures will not be
accepted on the receiving report.

NOTE: It is important that the date of receipt and the date of
acceptance entered in the certification on the receiving report be
accurate. Those dates are used to calculate the due date for payments,
and interest on overdue payments. The contracting/ordering officer or a
designated representative should certify receipt and authorize payment
by signing the certification on the receiving report.

\(2\) Invoices received by issuing offices or other designated program
offices must be time stamped to indicate the date of receipt, checked to
verify the accuracy of the invoiced amount, and forwarded within 5
workdays (after receipt of the invoice or acceptance of the supplies
and/or services, whichever is later), to the appropriate Finance
Division for payment. Copy 1 of the GSA Form 300/300-1 and a receiving
report (Copy 6 of the GSA Form 300/300-1 or GSA Form 3025/3025A,
Receiving Report) should be forwarded with the invoice to finance.

\(3\) When invoices are submitted directly to the Finance Division,
contracting/ordering offices or other designated program offices will
certify receipt and acceptance and authorize payment for supplies or
services by completing copy 6 of GSA Form 300/300-1 or the GSA Form
3025/3025A, Receiving Report, in accordance with paragraph (c)(1) above
and sending it to the appropriate Finance Division within 5 workdays
after supplies or services are received and accepted.

GSAM\
APD 2800.12B, 09-01-99 H-145

**553.370-353-I Instructions for completing GSA Form 353, Performance
Evaluation &\
Facilities Report (PEFR)**

\[509.106-2\]

\(a\) [Completing Section I - PCO Request]{.underline}**.** Blocks 1
through 8 are to be completed by the contract specialists/Procuring
Contracting Officer (PCO) requesting the PEFR.

[Block 1 - OFFEROR/CONTRACTOR]{.underline}.

[Block la - IDENTIFICATION (Name, address, telephone number, CEC, and
point of contact)]{.underline}. Enter the name, address, complete
telephone number (including area code), the Contractor Establishment
Code (CEC), and the name of the individual that is the
offeror/contractor\'s point of contact.

[Block lb - REPRESENTATION]{.underline}. Check the appropriate boxes
according to the offeror/contractor representations in the offer.

[Block 2 - INSPECTION POINT, IF DIFFERENT FROM ABOVE (Name , address,
telephone number, CEC, and point of contact)]{.underline}. If the
inspection point is at a separate location from the offeror/contractor
listed in Block 1, the PEFR should be requested at the inspection point.
The PEFR request should be sent to the Contract Management zone where
the inspection point is located, regardless of the location of the
production point.

Enter the name, address/location (no post office boxes), complete
telephone number (including area code), CEC, and, if available, the name
of the individual that is the point of contact at the inspection point.

If there are multiple inspection points, separate requests must be made
for each location. If multiple PEFRs are required for one
offeror/contractor due to multiple inspection points, use Block 5 to
notify the Quality Assurance Specialist (QAS) of all additional related
PEFRs.

[Block 3 - SOLICITATION/CONTRACT NUMBER AND ESTIMATED DOLLAR
VALUE]{.underline}. Enter the complete solicitation number, or contract
number in cases of options, and the estimated dollar value of the items
for which the offeror/contractor is being considered. If the PEFR is
being requested for the purpose of exercising an option (additional
quantity or extended period), enter the dollar value of the option only,
not the full contract value.

[Block 4 - SPECIAL REQUIREMENTS (Delivery, lst Article, Bid Sample, Buy
American, SBSA, MAS)]{.underline}. Enter the delivery requirements (in
number of days) and any special requirements that are applicable to the
procurement; e.g., first article sample, bid sample, Buy American Act
applies, Small Business Set Aside (SBSA), Multiple Award Schedule (MAS),
quick ship provisions, backup contract, options versus a base contract,
etc.

GSAM\
H-146 APD 2800.12B, 09-01-99

**553.370-353-I Instructions for completing GSA Form 353, Performance
Evaluation &\
Facilities Report (PEFR)**

If anything other than a complete PEFR is being requested, clearly
specify what limited information is needed. For example, in the case of
a MAS proposed award or exercising an option for additional quantities
or an extended period of tine, the PCO may request only certain
information rather than a full PEFR.

While the QAS cannot certify that the contractor/offeror is a small
business or qualifies as a dealer under the requirements of the
Walsh-Healey Act, the PCO may request that the QAS advise of any
conditions observed that would give reason to challenge the
contractor/offeror\'s representations as reflected in Block lb. The QAS
will address any issues regarding representations in Block 29.

[Block 5 - SPECIAL INFORMATION FOR CONTRACT MANAGEMENT]{.underline}.
Enter any special information that would assist the QAS or the
Administrative Contracting Officer (ACO) in evaluating the proposed
contractor, such as: protests received, any allegations made by
competitors that the PCO would like to have checked out, any information
on problems experienced with bid samples, etc.

As noted in (2) above, if multiple PEFRs have been requested due to
separate inspection points, so note. Specify the name and location (city
and state) of the additional inspection points. This will enable the QAS
and ACO to coordinate with other Regional Contract Management Divisions
if necessary.

[Block 6 - REASON FOR REQUEST (CAL/date, new supplier, new
product)]{.underline}. Enter the reason for the request; e.g.,
offeror/contractor is on the Contractor Alert List (CAL) (if so, state
the CAL date), new product, new supplier, no recent PEFR, etc. Explain
fully when the dollar value of the proposed award is below the small
purchase threshold.

[Block 7 - REQUESTER]{.underline}.

[Block 7a - REQUESTER (Name, organizational symbol, telephone number,
and FAX number)]{.underline}. Enter the typed/printed name of the
contract specialist/PCO making the PEFR request. The contract
specialist\'s signature, organizational symbol, complete telephone
number (including area code), and FAX number.

[Block 7b - DATE]{.underline}. Enter the date of the request.

[Block 8 - SOLICITATION ITEMS]{.underline}.

[Block 8a - ITEM NUMBER]{.underline}. Enter the solicitation/contract
item number. This will assist the QAS and ACO in readily identifying the
item in the solicitation/contract for which the offeror/contractor is
being considered.

GSAM\
APD 2800.12B, 09-01-99 H-147

**553.370-353-I Instructions for completing GSA Form 353, Performance
Evaluation &\
Facilities Report (PEFR)**

[Block 8b - NOMENCLATURE AND NSN]{.underline}. Enter the nomenclature
and national stock number (NSN), if applicable, for each item for which
the offeror/contractor is being considered.

[REQUIREMENTS (Units)]{.underline}.

[Block 8c - PEAK MONTHLY]{.underline}. For each item enter the
offeror/contractor\'s stated peak monthly supply potential. If the
offeror/contractor has not given its monthly supply potential, enter 125
percent of the Government\'s estimated monthly requirement.

[Block 8d - TOTAL]{.underline}. On definite quantity
solicitations/contracts, enter the total quantity required. If the PEFR
is being requested for exercising an optional quantity, enter the total
quantity of the option only, not the entire contract quantity. For other
contract types (requirements or indefinite quantity), enter the total
estimated quantity for the entire contract period.

\(b\) [Completing Section II - QAS EVALUATION]{.underline}**.** Blocks 9
and 14 through 30 are to be completed by the QAS. Blocks 9, 10, 11, and
13 are to be completed last. Blocks 10 through 12 are to be completed by
the Contract Management Division Director or his/her designee. Block 13
is to be completed by the Contract Management Division Director or
Acting Director. Authority to sign Block 13 shall not be delegated below
the level of Director, Contract Management Division.

[Block 9a - MONTHLY CAPACITY]{.underline}. Determine the maximum
production capacity. In making this determination, factors to be
considered should include, but are not limited to:

\(1\) Reviewing past production records on the same or similar items;

\(2\) Considering employment level and number of shifts in operation
during this period;

\(3\) Planning and scheduling of production equipment;

\(4\) Flexibility for reassignment of operation to alternate production
equipment; and

\(5\) Time required to test.

Enter the total quantity for each item that can be produced in one
month. Maximum production capacity must be determined by taking into
consideration all items being evaluated, all operating processes,
functions, equipment, and personnel.

[Block 9b - GOVERNMENT COMMITMENTS]{.underline}. Determine and verify
the number of units committed under existing Government contracts.

GSAM\
H-148 APD 2800.12B, 09-01-99

**553.370-353-I Instructions for completing GSA Form 353, Performance
Evaluation &\
Facilities Report (PEFR)**

[Block 9c - COMMERCIAL COMMITMENTS]{.underline}. Determine and verify
the number of units committed under existing commercial contracts.

[Block 9d - NET AVAILABLE]{.underline}. Subtract the total number of
units in b and c from the number of units in a, and enter the results in
Block 9d.

[Block 10 - SUMMARY OF ACO/QAS FINDINGS (Past performance, production
capacity, quality control system, representations, and favorable or
unfavorable factors)]{.underline}. This Block is to be completed by the
Contract Management Division Director, or his/her designee. Give a
summation of the past performance, production capability and capacity,
quality control system, purchasing, subcontracting procedures, problems
with representations, and records at the manufacturing plant on items
identical or similar-to the proposed award items.

[Block 11 - RECOMMENDATION]{.underline}. This Block is to be completed
by the Contract Management Division Director or his/her designee.

Check the appropriate box; i.e., capable of performing or incapable of
performing. One of the boxes must be checked.

[Block 12]{.underline}. This Block is to be completed by the Contract
Management Division Director or his/her designee.

[Block 12a - ZONE]{.underline}. The receiving Contract Management
Division shall enter the number of the zone where the survey will be
conducted.

[Block 12b - DATE RECEIVED]{.underline}. The surveying zone shall enter
the date the Contract Management Division received the request from the
procurement office.

[Block 12c - CONTROL NUMBER]{.underline}. The surveying zone shall enter
the control number assigned to the PEFR by the Contract Management
Division.

[Block 13 - APPROVAL: DIRECTOR, CONTRACT MANAGEMENT
DIVISION]{.underline}.

[Block 13a - PRINTED NAME]{.underline}. The typed or printed name of the
Contract Management Director approving the PEFR shall be entered in this
block.

[Block 13b - TELEPHONE NUMBER]{.underline}. Enter the telephone number
(including area code) of the Contract Management Division Director.

[Block 13c - SIGNATURE]{.underline}. After reviewing the completed form,
the Director, Contract Management Division, or the Acting Director,
shall sign the Form. Authority to approve the PEFR shall not be
delegated below this level. Signature indicates a full review of the
completed GSA Form 353 and agreement with its full contents.

GSAM\
APD 2800.12B, 09-01-99 H-149

**553.370-353-I Instructions for completing GSA Form 353, Performance
Evaluation &\
Facilities Report (PEFR)**

[Block 13d - DATE]{.underline}. Enter the date signed.

[Block 14 - TYPE OF COMPANY]{.underline}. Check corporation,
partnership, or other. If \"other,\" specify; e.g., sole proprietor,
etc.

[Block 15 - KEY PERSONNEL INTERVIEWED]{.underline}.

[Block 15a - NAME]{.underline}. List the name(s) of the individual(s)
interviewed.

[Block 15b - TITLE]{.underline}. Give the organizational title(s) of the
individual(s) interviewed.

[Block 15c. - YEARS WITH FIRM]{.underline}. Enter the number of years
each individual interviewed has been employed by the company.

[Block 16 - YEAR ESTABLISHED]{.underline}. Enter the year the current
company/division was established.

[Block 17 - PERSONNEL]{.underline}. In Block 17b, headed \"NO. ON
HAND\", enter the actual number of employees corresponding to the
categories listed in Block 17a; i.e., Production, Quality Assurance,
Engineering, and Administrative. If more employees are needed to produce
the solicitation/contract item(s), comment in Block 22. Indicate their
plans to recruit.

[Block 18 - PRODUCTION EQUIPMENT]{.underline}.

[Block 18a - ON HAND]{.underline}. List the major production equipment
necessary to produce the solicitation/contract item(s) physically in the
plant.

[Block 18b - QUANTITY]{.underline}. Enter the number of pieces of
equipment for each entry in Block 18a.

[Block 18c - CONDITION]{.underline}. Indicate whether the equipment is
in condition to adequately produce the solicitation/contract item(s).

[Block 19 - UNION AFFILIATION - DATE AGREEMENT EXPIRES]{.underline}.
List the union affiliations and the expiration date of each agreement.
Comment on any imminent strike or labor unrest conditions in Block 22.

[Block 20]{.underline}

[Block 20a - NUMBER OF SHIFTS]{.underline}. Enter the number of shifts
worked per day.

[Block 20b - HOURS PER SHIFT]{.underline}. Enter the number of hours
worked in each shift.

GSAM\
H-150 APD 2800.12B, 09-01-99

**553.370-353-I Instructions for completing GSA Form 353, Performance
Evaluation &\
Facilities Report (PEFR)**

[Block 21]{.underline}

[Block 21a - SQUARE METERS UNDER ROOF]{.underline}. Enter the total
number of square meters the offeror/contractor has under roof.

[Block 21b - MANUFACTURING]{.underline}. Enter the total number of
square meters the offeror/contractor uses for manufacturing.

[Block 21c - STORAGE]{.underline}. Enter the total number of square
meters the offeror/contractor uses for storage of raw materials,
components, and end items.

[Block 21d - CONSTRUCTION AND CONDITION]{.underline}. Describe the
construction and condition of the buildings.

[Block 2le - NUMBER OF BUILDINGS]{.underline}. Enter the number of
buildings at this location.

[Block 22 - COMMENTS (Adequacy of personnel, equipment, and
space)]{.underline}. Enter any comments relative to adequacy or
inadequacy of:

\(1\) Available personnel;

\(2\) Any imminent strike conditions;

\(3\) Equipment necessary to produce the solicitation/contract item(s);
and

\(4\) Space for manufacturing and storage.

[Block 23 - SPECIAL TOOLING (Quantity, condition, plans for procuring,
costs, delivery dates, and manufacturer\'s familiarity with use and
handling)]{.underline}. List any special tooling such as molding
equipment, special dyes, and special printing plates required to
fabricate the solicitation/contract item(s), showing quantity on hand
and present condition. If the necessary tooling is not on hand, enter
the source where it will be obtained and the costs. Determine that the
delivery dates of any new special tooling will meet contract delivery
dates. Indicate manufacturer\'s familiarity with use and handling.

[Block 24 - PRODUCTION METHODS (order tracking system, flow, assembly
line, production cycle time, parts manufactured, parts contracted
for/purchased]{.underline}). Determine the process utilized by the
offeror/contractor for tracking incoming Government purchase orders to
assure adequate controls are in place. Determine that production methods
are adequate to produce all items listed in Block 8 of this PEFR
request. Provide a narrative to describe the processes. Include a
listing of the significant items manufactured as well as those
purchased. Record the production cycle tine. List any deficiencies noted
and indicate what corrective action the offeror/contractor will take
before the start of the contract.

GSAM\
APD 2800.12B, 09-01-99 H-151

**553.370-353-I Instructions for completing GSA Form 353, Performance
Evaluation &\
Facilities Report (PEFR)**

[Block 25 - OTHER ITEM(S) PRODUCED (Using same machinery, tools,
equipment, and]{.underline} [personnel as solicitation/ contract
item(s))]{.underline}. List all item(s) (other than the
solicitation/contract items under evaluation) being produced, or
scheduled into production, that use the same machinery, tools,
equipment, and personnel required for the solicitation/contract item(s).

[Block 26 - QUALITY SYSTEM REQUIREMENTS]{.underline}

[Block 26a - DOCUMENTED QUALITY SYSTEM]{.underline}. Describe the
offeror/contractor\'s current documented quality procedure and overall
Conformance to the proposed contract requirements. Include a description
of how the contractor ensures that incoming materials conform to
contract requirements.

[Block 26b - ORGANIZATION AND MANAGEMENT RESPONSIBILITY]{.underline}.
Identify person(s) responsible and their authority in the quality
organization. Describe management policy, controls, and objectives.
Identify any training plan for personnel activities affecting quality.

[Block 26c - PROCESS AND SPECIAL PROCESS CONTROLS]{.underline}. Describe
process status controls, e.g., non-conforming material control, product
segregation and traceability (use of tags, labels, marking, etc.).
Identify process verification and inspection stations, as well as
controls where product and special process characteristics are
monitored.

[Block 26d - INSPECTION, MEASURING, AND TEST EQUIPMENT]{.underline}.
Identify inspection, tests, facilities, equipment, calibration plan, and
overall program adequacy. Also identify any outside test facilities to
be used. Explain the degree to which they will be utilized, and describe
their adequacy.

[Block 26e - USE OF STATISTICAL TECHNIQUES]{.underline}. Specify the
sampling plans and/or statistical process controls used by the
offeror/contractor. Determine if the plans are acceptable under the
contract requirements.

[Block 26f - QUALITY RECORDS]{.underline}. Describe the maintenance,
identification, collection, indexing, filing, storage and disposition of
records. Determine that the quality records adequately document the
process controls and the inspections and tests performed as provided in
the documented quality procedures.

[Block 26g - TECHNICAL DOCUMENT CONTROL AND COMMUNICATIONS]{.underline}.
Comment on the following:

\(1\) The offeror/contractor\'s control of technical documents,
drawings, specifications, standards, commercial item descriptions, item
purchase descriptions, etc., the control of changes to these documents,
and communication and distribution of information;

GSAM\
H-152 APD 2800.12B, 09-01-99

**553.370-353-I Instructions for completing GSA Form 353, Performance
Evaluation &\
Facilities Report (PEFR)**

\(2\) The adequacy of production technical documents;

\(3\) The contractor\'s understanding of the scope and nature of the
work required and the specific issue of the technical documents
involved; and

\(4\) Adequacy of controls and lines of communication between
contractor, suppliers, and vendors concerning contract administration
responsibilities.

[Block 26h - PACKAGING, PACKING, AND MARKING]{.underline}. Explain how
the offeror/contractor plans to fulfill the contract requirements for
packaging, packing (including palletization), and marking. Describe
plans to control the quality. Comment on the offeror/contractor\'s
understanding of any military requirements.

[Block 27 - EEO COMPLIANCE (From observation only)]{.underline}. To be
completed only when the potential contract will exceed \$10,000. The QAS
will observe, but not inquire of the bidder, whether the plant appears
to be in compliance with EEO clause (see FAR 52-222.26).

[Block 27a - ARE EEO POSTERS DISPLAYED WHERE ALL EMPLOYEES CAN READ
THEM]{.underline}? Check yes or no, as appropriate.

[Block 27b - GIVE ANY EVIDENCE OF SEGREGATED FACILITIES (Entrances,
exits, drinking fountains, eating, rest rooms]{.underline}, etc.). Enter
details of any segregated facilities noted except facilities such as
rest rooms or locker rooms segregated on the basis of gender.

[Block 28 - REMARKS AND ADDITIONAL COMMENTS]{.underline}. This Block is
to be used for continuation space for additional information from any
other blocks.

If the QAS is denied admittance, document the details and individuals
involved.

[Block 29 - QAS ANALYSIS AND RECOMMENDATION]{.underline}. Enter
information regarding the offeror/contractor\'s performance, such as,
synopsis of quality complaints, information on administrative holds,
related replacement actions, unresolved QDNs and/or unacceptable
performance with respect to timely corrective actions, etc.

If the offeror/contractor is on the CAL, the QAS shall specifically
address the criteria for which they were placed on the CAL, including
identifying and analyzing any corrective actions taken and the current
performance with regard to those CAL criteria.

Describe any favorable or unfavorable conditions that might affect
contractor\'s performance, considering familiarity with the product,
contract terms, technical documents, test requirements, and special
requirements. Note whether there are any deficiencies in meeting quality
system requirements and indicate their seriousness. State whether the
supplier

GSAM\
APD 2800.12B, 09-01-99 H-153

**553.370-353-I Instructions for completing GSA Form 353, Performance
Evaluation &\
Facilities Report (PEFR)**

appears reliable, is able to make changes before the start of
production, and is willing to correct deficiencies. Describe any reasons
to question or challenge the offeror/contractor\'s representations
(reflected in Block lb). Any additional remarks or comments can be
continued in Block 28 or on plain bond paper if space is needed.

**In this analysis, the QAS must specifically state a recommendation of
\"capable\" or \"incapable\" of performing.**

Enter any information available regarding other pending awards which
would represent commitments that may cause conflict on capacity if
awarded. Provide as much detail as possible, such as points of contact.

[Block 30 - QUALITY ASSURANCE SPECIALIST]{.underline}.

[Block 30a - PRINTED NAME]{.underline}. Enter the typed or printed name
of the QAS conducting the review and completing Section II of the PEFR.

[Block 30b - TELEPHONE NUMBER]{.underline}. Enter the telephone number
of the zonal office where questions regarding the PEFR are to be
fielded.

[Block 30c - SIGNATURE]{.underline}. The QAS shall sign the report. When
the GSA Form 353 is electronically transmitted, a signature is not
necessary.

[Block 30d - DATE]{.underline}. Enter the date the QAS portion is
completed and signed.

\(c\) [Completing Section III - PERFORMANCE HISTORY AND ACO
ANALYSIS]{.underline}.

Performance data must cover all current GSA contracts and small
purchases, as well as all GSA contracts and small purchases that have
been completed and/or terminated within the last three years.

If GSA contract performance data is not available, the ACO shall so
indicate, and request the QAS to obtain any performance data available
from the offeror/contractor on other Government or commercial contracts.

**NOTE:** At the discretion of the zone Contract Management Director,
Section III may be completed concurrently by the ACO while Section II is
being completed by the QAS, or completed by the ACO prior to forwarding
the PEFR to the QAS for completion of Section II.

[Block 31 - SUMMARY OF CONTRACTS (Beginning with the most recent
contract)]{.underline}. No blocks are to be left blank. If the number is
zero, enter \"0\". If the item is not applicable,

GSAM\
H-154 APD 2800.12B, 09-01-99

**553.370-353-I Instructions for completing GSA Form 353, Performance
Evaluation &\
Facilities Report (PEFR)**

enter \"N/A\" (This should be a rare circumstance). If the information
is not available or unknown, enter \"UKN\". Space is provided for two
contracts. List the data for the most recent contract first and continue
on to the oldest contract last. If the offeror/contractor has held more
than two contracts in the past three years, provide the data on
additional pages. If additional space is needed, duplicate page 7 of the
PEFR.

For Blocks 31b through 3lu enter the data as indicated below
corresponding to each contract listed in Block 31a.

[Block 31a - CONTRACT NUMBER]{.underline}. Enter the contract number.

[Block 31b - CONTRACT PERIOD]{.underline}. Enter the contract period;
i.e., the beginning and ending Julian dates.

[Block 31c FSC/NOMENCLATURE]{.underline}. Enter the FSC and
nomenclature.

[Block 31d TOTAL NUMBER OF PURCHASE ORDERS ISSUED]{.underline}.

Enter the total number of purchase orders issued.

[Block 3le - PERCENT POs DELINQUENT TO ORIGINAL DUE DATE]{.underline}.
Enter the percentage of purchase orders delinquent based on the original
due date; specifying in the spaces provided the number that were
Government Caused (GC) and the number that were Contractor Caused (CC).

[Block 31f - NUMBER PURCHASE ORDERS DELINQUENT]{.underline}. Enter the
number of purchase orders delinquent (16 or more days); specifying in
the spaces provided the number that were Government Caused (GC) and the
number that were Contractor Caused (CC).

[Block 3lg - PERCENT POs DELINQUENT (CC)]{.underline}. Divide the total
of contractor caused late purchase orders (Block 31f (CC)) by the total
number of purchase orders issued (Block 31d) to determine the percent of
purchase orders delinquent due to contractor failure. Enter the
resulting percentage.

[Block 31h - NUMBER OF PURCHASE ORDERS TERMINATED FOR
DEFAULT]{.underline}. Enter the number of purchase orders that were
terminated for default.

[Block 31i - PERCENT OF PURCHASE ORDERS TERMINATED FOR
DEFAULT]{.underline}. Divide the number of purchase orders terminated
for default (Block 31i) by the total number of purchase orders issued
(Block 31d). Enter the resulting percentage.

[Block 31j - NUMBER QDNs]{.underline}. Enter the number of Quality
Deficiency Notices (QDNs) issued.

GSAM\
APD 2800.12B, 09-01-99 H-155

**553.370-353-I Instructions for completing GSA Form 353, Performance
Evaluation &\
Facilities Report (PEFR)**

[Block 31k - NUMBER CURE LETTERS]{.underline}. Enter the number of Cure
Letters issued.

[Block 311 - NUMBER SHOW CAUSE LETTERS]{.underline}. Enter the number of
Show Cause Letters issued.

[Block 31m - LABORATORY]{.underline}. In the space labeled \"Number
Tests\", enter the total number of laboratory submissions conducted. In
the second space, labeled \"Number Failed\", enter the number of
laboratory submissions where the item(s) tested failed to meet
requirements. In the third space, labeled \"Percent of Test Failed,\"
enter the percent of the laboratory submissions which failed. To derive
the percent, divide the number of failed submissions) by the total
number of submissions)

[Block 31n - DEVIATION]{.underline}. Deviations are request(s) by the
contractor for changes in requirements prior to the beginning of
production. In the first space, labeled \"GC\" (Government caused),
enter the number of deviations granted that were caused by the
Government; e.g., faulty Government technical documents. In the second
space, labeled \"CC\" (contractor caused), enter the number of
deviations granted that were caused by the contractor.

[Block 31o - lst ARTICLE]{.underline}. If no First Article sample was
required under the contract, check \"N/A.\" If a First Article was
required, check \"yes\" or \"no\" in the space labeled \"On Time\" to
show whether the contractor offered the sample on time. In the space
labeled \"1st Submission or Accepted,\" check \"yes\" or \"no\" to show
whether the first submission of the first article sample was accepted.

[Block 31p - NONCONFORMING SUPPLIES ACCEPTED]{.underline}. Enter the
number of purchase orders where nonconforming supplies were accepted by
the Government.

[Block 3lq - COMPLAINTS]{.underline}. In the space under \"Complaints\"
labeled \"Total\" enter the total number of customer complaints
received. In the space labeled \"Number Contractor Liable\" enter the
number of complaints with contractor liability that were found to be
justified following investigation. In the space labeled \"Number
Category I\" enter the number of complaints that were determined to be
Category I complaints. In the final space under \"Complaints\" labeled
\"Number Failed Correct\" enter the number of complaints where the
contractor failed to take timely and adequate corrective action.

[Block 3lr - HOLDS]{.underline}. List only those holds that are over 90
calendar days old. In the space under \"Holds\" labeled \"Type\" enter
the type of hold; e.g., 51 - Quality; 53 - Litigation, etc. In the space
labeled \"Age\" enter the age of the hold in terms of calendar days. In
Block \"t. - ACO COMMENTS\" for the specified contract, provide a brief
narrative on the hold. Describe any problems resulting from the
contractor\'s failure to resolve the situation.

GSAM\
H-156 APD 2800.12B, 09-01-99

**553.370-353-I Instructions for completing GSA Form 353, Performance
Evaluation &\
Facilities Report (PEFR)**

[Block]{.underline} [31s - CONTRACT TERMINATED FOR DEFAULT]{.underline}.
Check the \"Yes\" or \"No\" box, indicating whether the contract was
terminated for default. Provide details in Block 31t.

[Block 31t - ACO COMMENTS]{.underline}. Enter any additional information
for the contract specified. Provide an explanation of the data and an
evaluation of the contractor\'s performance under this specific
contract.

[Block 32 - SUMMARY OF SMALL PURCHASES]{.underline}.

[Block 32a - TOTAL NUMBER OF PURCHASE ORDERS ISSUED]{.underline}. Enter
the total number of small purchase orders issued to the
offeror/contractor over the past three years.

[Block 32b - TOTAL DOLLAR VALUE]{.underline}. Enter the total dollar
value of all small purchase orders issued to the offeror/contractor over
the past three years.

[Block 32c - 32o]{.underline}. Enter data in accordance with the
instructions for Blocks 3le - 3lr with the corresponding headings.

[Block 32p - ACO COMMENTS (Small Purchases)]{.underline}. Enter any
additional information to the data listed. Provide an explanation of the
data and an evaluation of the contractor\'s performance on small
purchases.

[Block 33 - ACO SUMMARY ANALYSIS OF OVERALL PERFORMANCE AND
RECOMMENDATION]{.underline}. Provide a detailed analysis of all data
gathered. Evaluate the offeror/contractor\'s past performance, current
standing, and potential for future performance. Identify any patterns of
improvement or deterioration in performance. **In this analysis, the ACO
must specifically state a recommendation of \"award\" or \"no award.\"**

[Block 34 - ADMINISTRATIVE CONTRACTING OFFICER]{.underline}.

[Block 34a - PRINTED NAME]{.underline}. Enter the typed or printed name
of the ACO conducting the review and completing Section III of the PEFR.

[Block 34b - TELEPHONE NUMBER]{.underline}. Enter the telephone number
where the ACO can be reached.

[Block 34c - SIGNATURE]{.underline}. The ACO shall sign the report.

[Block 34d - DATE]{.underline}. Enter the date the ACO portion is
completed and signed.

[Copies and distribution]{.underline}. A separate GSA Form 353 must be
used for each inspection point. An original and 3 copies of the GSA Form
353 must be prepared. The original and first copy must be forwarded to
the Quality Assurance Branch in the zone in which the facilities

GSAM\
APD 2800.12B, 09-01-99 H-157

**553.370-353-I Instructions for completing GSA Form 353, Performance
Evaluation &\
Facilities Report (PEFR)**

are located. The second copy must be sent to the Quality Assurance
Division, Central office, and the third copy retained as the file copy.
The original and each of the two forwarded copies must be accompanied
by:

\(1\) A copy of the solicitation;

\(2\) A copy of all pertinent information submitted by the offeror,
including delivery time, and where applicable, the offeror\'s indicated
monthly production capacity or supply potential (in lieu of extracting
such information from the offer, copies of the offer or pertinent pages
thereof may be furnished);

\(3\) Any pertinent correspondence between GSA and the offeror; and

\(4\) Any other information the buying activity has which should be
considered by the Quality Assurance Branch in making the evaluation.

GSAM\
H-158 APD 2800.12B, 09-01-99

**553.370-618D Statement to be Submitted When Work is Performed
Personally.**

![](media/image1.png){width="6.491666666666666in"
height="7.831944444444445in"}

GSAM\
APD 2800.12B, 09-01-99 H-159

**553.370-1378 Record of, and Receipt for, Bids and Responses.**

![](media/image2.png){width="5.995138888888889in"
height="7.479166666666667in"} GSAM\
H-160 APD 2800.12B, 09-01-99

**53.370-1458 Motor Vehicle Shop Work Order, Repair and Purchase
Order.**

![](media/image3.png){width="6.489583333333333in"
height="8.577777777777778in"} GSAM\
APD 2800.12B, 09-01-99 H-161

**553.370-1458 Motor Vehicle Shop Work Order, Repair and Purchase
Order.**

![](media/image4.png){width="6.497222222222222in"
height="8.553472222222222in"} GSAM\
H-162 APD 2800.12B, 09-01-99

**553.370-1535A Recommendation for Award(s) (Continuation).**

![](media/image5.png){width="5.991666666666666in"
height="7.528472222222222in"}

GSAM\
APD 2800.12B, 09-01-99 H-163

**553.370-1602 Notice Concerning Solicitation.**

![](media/image6.png){width="6.4944444444444445in"
height="8.361805555555556in"}

**553.370-1678 Status Report of Orders and Shipments.**

![](media/image7.png){width="6.499305555555556in"
height="8.174305555555556in"}

GSAM\
APD 2800.12B, 09-01-99 H-165

**553.370-1678 Status Report of Orders and Shipments.**

![](media/image8.png){width="6.493055555555555in"
height="8.310416666666667in"} GSAM\
H-166 APD 2800.12B, 09-01-99

**553.370-1720 Request for Release of Classified Information to U.S.
Industry.**

![](media/image9.png){width="6.49375in" height="8.209722222222222in"}
GSAM\
APD 2800.12B, 09-01-99 H-167

**553.370-1720 Request for Release of Classified Information to U.S.
Industry.**

![](media/image10.png) GSAM\
H-168 APD 2800.12B, 09-01-99

**553.370-1766 Structured Approach Profit/Fee Objective.**

![](media/image11.png){width="6.4875in" height="8.045833333333333in"}

GSAM\
APD 2800.12B, 09-01-99 H-169

**553.370-2689 Procurement Not Set Aside.**

![](media/image12.png){width="6.496527777777778in"
height="8.208333333333334in"} GSAM\
H-170 APD 2800.12B, 09-01-99

**553.370-2728 Procurement Contract Register.**

![](media/image13.png){width="5.908333333333333in"
height="8.529861111111112in"} GSAM\
APD 2800.12B, 09-01-99 H-171

**553.370-3186 Order for Supplies or Services.**

![](media/image14.png){width="6.489583333333333in"
height="8.334722222222222in"} GSAM\
H-172 APD 2800.12B, 09-01-99

**553.370-3186 Order for Supplies or Services.**

![](media/image15.png){width="6.489583333333333in"
height="8.400694444444444in"} GSAM\
APD 2800.12B, 09-01-99 H-173

**553.370-3186B Order for Supplies or Services (EDI).**

![](media/image16.png){width="6.499305555555556in"
height="8.217361111111112in"}

**553.370-3410 Request for Appointment.**

![](media/image17.png){width="6.088888888888889in"
height="8.152083333333334in"}

GSAM\
APD 2800.12B, 09-01-99 H-175

**553.370-3471 Abstract of Offers.**

![](media/image18.png){width="6.175in" height="8.386805555555556in"}
GSAM\
H-176 APD 2800.12B, 09-01-99

**553.370-3521 Blanket Purchase Agreement.**

![](media/image19.png){width="6.495138888888889in" height="7.98125in"}

GSAM\
APD 2800.12B, 09-01-99 H-177

**553.370-3521 Blanket Purchase Agreement.**

![](media/image20.png){width="6.489583333333333in"
height="8.213194444444444in"} GSAM\
H-178 APD 2800.12B, 09-01-99

**553.370-3521 Blanket Purchase Agreement.**

![](media/image21.png){width="6.488194444444445in"
height="8.216666666666667in"}

GSAM\
APD 2800.12B, 09-01-99 H-179

**553.370-3521 Blanket Purchase Agreement.**

![](media/image22.png){width="6.499305555555556in"
height="8.053472222222222in"}

GSAM\
H-180 APD 2800.12B, 09-01-99

**553.370-3577 Notice to Unsuccessful Offeror of Contract Award.**

![](media/image23.png){width="5.748611111111111in"
height="8.120833333333334in"}

**553.370-3611 Cover Page Source Selection Information.**

![](media/image24.png)(Next page is H-185) GSAM\
H-182 APD 2800.12B, CHGE 1, 10-1-99

**553.370-8002A Motor Vehicle Requisition Status.**

![](media/image25.png){width="6.5in" height="4.565972222222222in"}

GSAM\
APD 2800.12B, 09-01-99 H-185

**553.370-8002B Motor Vehicle Delivery Order.**

![](media/image26.png){width="6.4944444444444445in"
height="8.171527777777778in"}