FEDERAL SUPPLY SCHEDULE

65IIA Medical Equipment & Supplies

**Request for Modification Form**

  -------------------- ----------------------------------------------------
  **CONTRACTOR NAME**       

  **CONTRACT#**             

  **ADDRESS1**              

  **ADDRESS2**              

  **CITY/STATE/ZIP**        

  **PHONE**                 

  **EMAIL**                 

  **DATE SUBMITTED TO       
  VA-NAC**             
  -------------------- ----------------------------------------------------

Provide the following information for **PRODUCT ADDITIONS**

+------------+------------------+-----------+-------------------------+
| **         | **REQUIREMENT**  | **C       |                         |
| CONTRACTOR |                  | OMMENTS** |                         |
| C          |                  |           |                         |
| HECKLIST** |                  |           |                         |
+------------+------------------+-----------+-------------------------+
| COMPLETE   | SPECIAL ITEM     |           |                         |
|            | NUMBER (SIN)     |           |                         |
| INCOMPLETE | CATEGORY(IES)    |           |                         |
+------------+------------------+-----------+-------------------------+
| COMPLETE   | DELIVERY TIME    | Within    |                         |
|            |                  | **     ** |                         |
| INCOMPLETE |                  | days      |                         |
|            |                  | after     |                         |
|            |                  | receipt   |                         |
|            |                  | of order  |                         |
|            |                  | (ARO)     |                         |
+------------+------------------+-----------+-------------------------+
| COMPLETE   | MANUFACTURING    | **NAME**  |                         |
|            | NAME & ADDRESS   |           |                         |
| INCOMPLETE |                  |           |                         |
|            |                  |           |                         |
| NA         |                  |           |                         |
+------------+------------------+-----------+-------------------------+
|            |                  | **        |                         |
|            |                  | ADDRESS** |                         |
+------------+------------------+-----------+-------------------------+
|            |                  | **POC**   |                         |
+------------+------------------+-----------+-------------------------+
|            |                  | **PHONE** |                         |
+------------+------------------+-----------+-------------------------+
|            |                  | **EMAIL** |                         |
+------------+------------------+-----------+-------------------------+
| COMPLETE   | DATED COMMERCIAL | **NOTE:** |                         |
|            | PRICELIST        | If a      |                         |
| INCOMPLETE |                  | dated     |                         |
|            |                  | c         |                         |
| NA         |                  | ommercial |                         |
|            |                  | pricelist |                         |
|            |                  | is not    |                         |
|            |                  | available |                         |
|            |                  | provide   |                         |
|            |                  | the       |                         |
|            |                  | internal  |                         |
|            |                  | pricing   |                         |
|            |                  | documents |                         |
|            |                  | that      |                         |
|            |                  | identify  |                         |
|            |                  | the list  |                         |
|            |                  | price of  |                         |
|            |                  | the items |                         |
|            |                  | proposed  |                         |
|            |                  | and       |                         |
|            |                  | verify    |                         |
|            |                  | that this |                         |
|            |                  | pricing   |                         |
|            |                  | is true   |                         |
|            |                  | and       |                         |
|            |                  | correct.  |                         |
|            |                  | This      |                         |
|            |                  | document  |                         |
|            |                  | must be   |                         |
|            |                  | signed    |                         |
|            |                  | and dated |                         |
|            |                  | by an     |                         |
|            |                  | a         |                         |
|            |                  | uthorized |                         |
|            |                  | s         |                         |
|            |                  | ignatory. |                         |
+------------+------------------+-----------+-------------------------+
| COMPLETE   | ACTUAL ANNUAL    |   -       |                         |
|            | **COMMERCIAL**   | --------  |                         |
| INCOMPLETE | SALES FOR THE    | --------- |                         |
|            | LAST 12 MONTHS   |           |                         |
|            |                  |  **SIN    |                         |
|            |                  |   \$      |                         |
|            |                  |           |                         |
|            |                  |     **    |                         |
|            |                  |           |                         |
|            |                  |           |                         |
|            |                  |  **SIN    |                         |
|            |                  |   \$      |                         |
|            |                  |           |                         |
|            |                  |     **    |                         |
|            |                  |           |                         |
|            |                  |           |                         |
|            |                  |  **SIN    |                         |
|            |                  |   \$      |                         |
|            |                  |           |                         |
|            |                  |     **    |                         |
|            |                  |           |                         |
|            |                  |           |                         |
|            |                  |  **SIN    |                         |
|            |                  |   \$      |                         |
|            |                  |           |                         |
|            |                  |     **    |                         |
|            |                  |           |                         |
|            |                  |           |                         |
|            |                  |  **SIN    |                         |
|            |                  |   \$      |                         |
|            |                  |           |                         |
|            |                  |     **    |                         |
|            |                  |           |                         |
|            |                  |           |                         |
|            |                  |  **SIN    |                         |
|            |                  |   \$      |                         |
|            |                  |           |                         |
|            |                  |     **    |                         |
|            |                  |   -       |                         |
|            |                  | --------  |                         |
|            |                  | --------- |                         |
+------------+------------------+-----------+-------------------------+
| COMPLETE   | ESTIMATED OR     |   -       |                         |
|            | ACTUAL ANNUAL    | --------  |                         |
| INCOMPLETE | **GOVERNMENT**   | --------- |                         |
|            | SALES            |           |                         |
|            |                  |  **SIN    |                         |
|            |                  |   \$      |                         |
|            |                  |           |                         |
|            |                  |     **    |                         |
|            |                  |           |                         |
|            |                  |           |                         |
|            |                  |  **SIN    |                         |
|            |                  |   \$      |                         |
|            |                  |           |                         |
|            |                  |     **    |                         |
|            |                  |           |                         |
|            |                  |           |                         |
|            |                  |  **SIN    |                         |
|            |                  |   \$      |                         |
|            |                  |           |                         |
|            |                  |     **    |                         |
|            |                  |           |                         |
|            |                  |           |                         |
|            |                  |  **SIN    |                         |
|            |                  |   \$      |                         |
|            |                  |           |                         |
|            |                  |     **    |                         |
|            |                  |           |                         |
|            |                  |           |                         |
|            |                  |  **SIN    |                         |
|            |                  |   \$      |                         |
|            |                  |           |                         |
|            |                  |     **    |                         |
|            |                  |           |                         |
|            |                  |           |                         |
|            |                  |  **SIN    |                         |
|            |                  |   \$      |                         |
|            |                  |           |                         |
|            |                  |     **    |                         |
|            |                  |   -       |                         |
|            |                  | --------  |                         |
|            |                  | --------- |                         |
+------------+------------------+-----------+-------------------------+
| YES        | PRIME VENDOR     | Is/Are    |                         |
|            |                  | the       |                         |
| NO         |                  | p         |                         |
|            |                  | roduct(s) |                         |
|            |                  | offered   |                         |
|            |                  | for       |                         |
|            |                  | dis       |                         |
|            |                  | tribution |                         |
|            |                  | under the |                         |
|            |                  | VA Prime  |                         |
|            |                  | Vendor    |                         |
|            |                  | Program?  |                         |
+------------+------------------+-----------+-------------------------+

+------------+------------------+--------------------------------------+
| **         | **REQUIREMENT**  | **COMMENTS**                         |
| CONTRACTOR |                  |                                      |
| C          |                  |                                      |
| HECKLIST** |                  |                                      |
+------------+------------------+--------------------------------------+
| COMPLETE   | MOST FAVORED     | MFC:                                 |
|            | CUSTOMER (MFC)   |                                      |
| INCOMPLETE |                  | **NOTE:** If the MFC differs from    |
|            |                  | the one upon which the contract      |
|            |                  | award was predicated complete the    |
|            |                  | enclosed Commercial Sales Practices  |
|            |                  | Form (CSP-1)                         |
|            |                  |                                      |
|            |                  | > CSP-1 COMPLETE                     |
|            |                  | >                                    |
|            |                  | > CSP-1 NOT REQUIRED                 |
+------------+------------------+--------------------------------------+
| COMPLETE   | TRACKING         |   ------------ --------------------  |
|            | CUSTOMER (TC)    |   **TC**       **TC NAME**           |
| INCOMPLETE |                  |                                      |
|            |                  |   CURRENT TC                         |
|            |                  |                                      |
|            |                  |   PROPOSED TC                        |
|            |                  |   ------------ --------------------  |
+------------+------------------+--------------------------------------+
| YES        | PROPOSED PRICING | Based on your written discounting    |
|            |                  | policies (standard commercial sales  |
| NO         |                  | practices in the event you do not    |
|            |                  | have written discounting policies),  |
|            |                  | are the discounts and any            |
|            |                  | concessions which you offer the      |
|            |                  | Government equal to or better than   |
|            |                  | your best price (discount and        |
|            |                  | concessions in any combination)      |
|            |                  | offered to any customer acquiring    |
|            |                  | the same items regardless of         |
|            |                  | quantity or terms and conditions?    |
|            |                  |                                      |
|            |                  | IF **NO**, complete the enclosed     |
|            |                  | Commercial Sales Practices Form      |
|            |                  | (CSP-1) and disclose **all**         |
|            |                  | commercial customers receiving       |
|            |                  | discounts greater than the proposed  |
|            |                  | Government pricing.                  |
+------------+------------------+--------------------------------------+
| YES        | DISCOUNT         | Do any deviations from your written  |
|            | POLICIES         | policies or standard commercial      |
| NO         |                  | sales practices disclosed in the     |
|            |                  | above chart ever result in better    |
|            |                  | discounts (lower prices) or          |
|            |                  | concessions than indicated?          |
|            |                  |                                      |
|            |                  | **If YES**, explain deviations in    |
|            |                  | accordance with the instructions     |
|            |                  | below:                               |
|            |                  |                                      |
|            |                  | Your explanation should include a    |
|            |                  | discussion of situations that lead   |
|            |                  | to deviations from standard          |
|            |                  | practice, an explanation of how      |
|            |                  | often they occur, and the controls   |
|            |                  | you employ to assure the integrity   |
|            |                  | of your pricing. Examples of typical |
|            |                  | deviations may include, but are not  |
|            |                  | limited to, one time goodwill        |
|            |                  | discounts to charity organizations   |
|            |                  | or to compensate an otherwise        |
|            |                  | disgruntled customer; a limited sale |
|            |                  | of obsolete or damaged goods; the    |
|            |                  | sale of sample goods to a new        |
|            |                  | customer; or the sales of prototype  |
|            |                  | goods for testing purposes.          |
+------------+------------------+--------------------------------------+
| **         | **REQUIREMENT**  | **COMMENTS**                         |
| CONTRACTOR |                  |                                      |
| C          |                  |                                      |
| HECKLIST** |                  |                                      |
+------------+------------------+--------------------------------------+
| COMPLETE   | PRODUCT          | Submit a spreadsheet that includes   |
|            | ADDITIONS PRICE  | the following information:           |
| INCOMPLETE | PROPOSAL         |                                      |
|            |                  | SIN#                                 |
|            |                  |                                      |
|            |                  | Item#                                |
|            |                  |                                      |
|            |                  | Product Description                  |
|            |                  |                                      |
|            |                  | Quantity/Unit of Measure             |
|            |                  |                                      |
|            |                  | Commercial List Price                |
|            |                  |                                      |
|            |                  | Proposed Gov't Discount off          |
|            |                  | Commercial List Price                |
|            |                  |                                      |
|            |                  | MFC Discount                         |
|            |                  |                                      |
|            |                  | MFC Net Price                        |
|            |                  |                                      |
|            |                  | Proposed NET FSS Price (w/ IFF &     |
|            |                  | Freight)                             |
+------------+------------------+--------------------------------------+
| COMPLETE   | QUANTITY         | Identify any proposed additional     |
|            | DISCOUNTS        | quantity discounts offered to the    |
| INCOMPLETE |                  | Government                           |
|            |                  |                                      |
|            |                  |                                      |
+------------+------------------+--------------------------------------+
| COMPLETE   | ADDITIONAL       | Identify any proposed additional     |
|            | DISCOUNTS        | discounts/concessions, including     |
| INCOMPLETE |                  | prompt payment discounts, annual     |
|            |                  | rebates, etc. provided to your       |
|            |                  | commercial customers.                |
|            |                  |                                      |
|            |                  |                                      |
+------------+------------------+--------------------------------------+
| COMPLETE   | PROPOSED FOB     | FOB DESTINATION                      |
|            | TERMS            |                                      |
| INCOMPLETE |                  | 48 Continental States & DC w/ point  |
|            |                  | of exportation (POE)                 |
|            |                  |                                      |
|            |                  | to AK, HI, PR                        |
|            |                  |                                      |
|            |                  | 50 States & DC w/ POE to PR          |
|            |                  |                                      |
|            |                  | 50 States, DC, & PR                  |
+------------+------------------+--------------------------------------+

**Column 1**---**Identify the applicable customer or category of
customer**. A \"customer\" is any entity, except the Federal Government,
which acquires supplies or services from the Offeror. The term customer
includes, but is not limited to: original equipment manufacturers, value
added resellers, state and local governments, distributors, educational
institutions (an elementary, junior high, or degree granting school
which maintains a regular faculty and established curriculum and an
organized body of students), dealers, national accounts, and end users.
In any instance where the Offeror is asked to disclose information for a
customer, the Offeror may disclose information by category of customer
if the offeror\'s discount policies or practices are the same for all
customers in the category. (Use a separate line for each customer or
category of customer.)

**Column 2---Identify the discount.** The term "discount" is as defined
in solicitation clause 552.212-70, Preparation of Offer (Multiple Award
Schedule). Indicate the best discount (based on your written discounting
policies or standard commercial discounting practices if you do not have
written discounting policies) at which you sell to the customer or
category of customer identified in column 1, without regard to quantity;
terms and conditions of the agreements under which the discounts are
given; and whether the agreements are written or oral. Net prices or
discounts off of other price lists should be expressed as percentage
discounts from the price list which is the basis of your offer. If the
discount disclosed is a combination of various discounts (prompt
payment, quantity, etc.), the percentage should be broken out for each
type of discount.

If the price lists which are the basis of the discounts given to the
customers identified in the chart are different than the price list
submitted upon which your offer is based, identify the type or title and
date of each price list. The contracting officer may require submission
of these price lists. To expedite evaluation, offerors may provide these
price lists at the time of submission.

**Column 3---Identify the quantity or volume of sales.** Insert the
minimum quantity or sales volume which the identified customer or
category of customer must either purchase/order, per order or within a
specified period, to earn the discount. When purchases/orders must be
placed within a specified period to earn a discount indicate the time
period.

**Column 4---Indicate the FOB delivery term for each identified
customer.** See FAR 47.3 for an explanation of FOB delivery terms.

**Column 5---Indicate concessions regardless of quantity granted to the
identified customer or category of customer.** Concessions are defined
in solicitation clause 552.212-70, Preparation of Offers (Multiple Award
Schedule). If the space provided is inadequate, the disclosure should be
made on a separate sheet by reference.

If deviations from your written policies or standard commercial sales
practices disclosed in the chart on the Commercial Sales Practices
Format are so significant and/or frequent that the Contracting Officer
cannot establish whether the price(s) offered is fair and reasonable,
then you may be asked to provide additional information. The Contracting
Officer may ask for information to demonstrate that you have made
substantial sales of the item(s) in the commercial market consistent
with the information reflected on the chart on the Commercial Sales
Practice Format, a description of the conditions surrounding those sales
deviations, or other information that may be necessary in order for the
Contracting Officer to determine whether your offered price(s) is fair
and reasonable. In cases where additional information is requested, the
Contracting Officer will target the request in order to limit the
submission of data to that needed to establish the reasonableness of the
offered price.

**CSP-1 Commercial Sales Practices Format**

  ---------------- ------------- ------------------- -------------- --------------
  **Column 1---\   **Column      **Column 3          **Column 4---\ **Column 5---\
  Customer**       2---\         Quantity/Volume**   FOB Term       Additional
                   Discount**                        (Destination   Discounts or
                                                     or Origin)**   Concessions
                                                                    (Include PPD &
                                                                    Annual
                                                                    Rebate)**

                                                                         

                                                                         

                                                                         

                                                                         

                                                                         

                                                                         

                                                                         

                                                                         

                                                                         

                                                                         

                                                                         

                                                                         

                                                                         

                                                                         

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

I,
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
verify that items offered are not replacements for previously deleted
items with a lower cost.

**AUTHORIZED REPRESENTATIVE DATE**

APPROVED APPROVED AS AMENDED DISAPPROVED

**CONTRACTING OFFICER DATE**

**EFFECTIVE DATE OF MODIFICATION**

**NOTE**: The effective date of the modification will be determined at
the time of approval of the request by the Contracting Officer.
**[Effective dates will be assigned as either the 1st or 15th of the
month.]{.underline}**

**Contractors are reminded that they must update their NAC-CM database
and GSA Advantage! files and provide the CO with an updated paper
pricelist for approval within 30 days of receiving an executed copy of
the requested modification.**

  -------------------- ----------------------------------------------------
  **CONTRACTOR NAME**       

  **CONTRACT#**             

  **ADDRESS1**              

  **ADDRESS2**              

  **CITY/STATE/ZIP**        

  **PHONE**                 

  **EMAIL**                 

  **DATE SUBMITTED TO       
  VA-NAC**             
  -------------------- ----------------------------------------------------

Provide the following information for **PRODUCT DELETIONS**

+------------+------------------+-------------------------------------+
| **         | **REQUIREMENT**  | **COMMENTS**                        |
| CONTRACTOR |                  |                                     |
| C          |                  |                                     |
| HECKLIST** |                  |                                     |
+------------+------------------+-------------------------------------+
| COMPLETE   | SPECIAL ITEM     |                                     |
|            | NUMBER (SIN)     |                                     |
| INCOMPLETE | CATEGORY(IES)    |                                     |
+------------+------------------+-------------------------------------+
| COMPLETE   | PRODUCT          | Submit a spreadsheet that includes  |
|            | DELETIONS        | the following information:          |
| INCOMPLETE |                  |                                     |
|            |                  | SIN#                                |
|            |                  |                                     |
|            |                  | Item#                               |
|            |                  |                                     |
|            |                  | Product Description                 |
|            |                  |                                     |
|            |                  | Quantity/Unit of Measure            |
|            |                  |                                     |
|            |                  | Reason for Deletion                 |
+------------+------------------+-------------------------------------+

**AUTHORIZED REPRESENTATIVE DATE**

APPROVED APPROVED AS AMENDED DISAPPROVED

**CONTRACTING OFFICER DATE**

**EFFECTIVE DATE OF MODIFICATION**

**NOTE**: The effective date of the modification will be determined at
the time of approval of the request by the Contracting Officer.
**[Effective dates will be assigned as either the 1st or 15th of the
month.]{.underline}**

**Contractors are reminded that they must update their NAC-CM database
and GSA Advantage! files and provide the CO with an updated paper
pricelist for approval within 30 days of receiving an executed copy of
the requested modification.**

  -------------------- ----------------------------------------------------
  **CONTRACTOR NAME**       

  **CONTRACT#**             

  **ADDRESS1**              

  **ADDRESS2**              

  **CITY/STATE/ZIP**        

  **PHONE**                 

  **EMAIL**                 

  **DATE SUBMITTED TO       
  VA-NAC**             
  -------------------- ----------------------------------------------------

Provide the following information for **PRICE INCREASE**

+------------+------------------+-------------------------------------+
| **         | **REQUIREMENT**  | **COMMENTS**                        |
| CONTRACTOR |                  |                                     |
| C          |                  |                                     |
| HECKLIST** |                  |                                     |
+------------+------------------+-------------------------------------+
| COMPLETE   | SPECIAL ITEM     |                                     |
|            | NUMBER (SIN)     |                                     |
| INCOMPLETE | CATEGORY(IES)    |                                     |
+------------+------------------+-------------------------------------+
| COMPLETE   | PRICE INCREASE   | Submit a spreadsheet that includes  |
|            | PROPOSAL         | the following information:          |
| INCOMPLETE |                  |                                     |
|            |                  | SIN#                                |
|            |                  |                                     |
|            |                  | Item#                               |
|            |                  |                                     |
|            |                  | Product Description                 |
|            |                  |                                     |
|            |                  | Quantity/Unit of Measure            |
|            |                  |                                     |
|            |                  | Previous Commercial List Price      |
|            |                  |                                     |
|            |                  | Current Commercial List Price       |
|            |                  |                                     |
|            |                  | Current FSS Pricing                 |
|            |                  |                                     |
|            |                  | Proposed NET FSS Price              |
|            |                  |                                     |
|            |                  | % FSS Change                        |
|            |                  |                                     |
|            |                  | Previous Tracking Customer Price    |
|            |                  |                                     |
|            |                  | Current Tracking Customer Price     |
|            |                  |                                     |
|            |                  | % Tracking Customer Change          |
|            |                  |                                     |
|            |                  | Awarded FSS Tracking Customer Ratio |
+------------+------------------+-------------------------------------+
| COMPLETE   | PRODUCT          | Product was added at:               |
|            | INFORMATION      |                                     |
| INCOMPLETE |                  | > TIME OF AWARD                     |
|            |                  | >                                   |
| NA         |                  | > MODIFICATION#                     |
|            |                  | >                                   |
|            |                  | > MODIFICATION EFFECTIVE DATE       |
+------------+------------------+-------------------------------------+
| COMPLETE   | DATED COMMERCIAL | **NOTE:** If a dated commercial     |
|            | PRICELIST        | pricelist is not available provide  |
| INCOMPLETE |                  | the internal pricing documents that |
|            |                  | identify the list price of the      |
| NA         |                  | items proposed and verify that this |
|            |                  | pricing is true and correct. This   |
|            |                  | document must be signed and dated   |
|            |                  | by an authorized signatory.         |
+------------+------------------+-------------------------------------+
| YES        | PRIME VENDOR     | Is/Are the product(s) offered for   |
|            |                  | distribution under the VA Prime     |
| NO         |                  | Vendor Program?                     |
+------------+------------------+-------------------------------------+

I,
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
verify that not adverse change has occurred in the ratio between the
awarded FSS price and the tracking customer price since the award of the
item.

**AUTHORIZED REPRESENTATIVE DATE**

APPROVED APPROVED AS AMENDED DISAPPROVED

**CONTRACTING OFFICER DATE**

**EFFECTIVE DATE OF MODIFICATION**

**NOTE**: The effective date of the modification will be determined at
the time of approval of the request by the Contracting Officer.
**[Effective dates will be assigned as either the 1st or 15th of the
month.]{.underline}**

**Contractors are reminded that they must update their NAC-CM database
and GSA Advantage! files and provide the CO with an updated paper
pricelist for approval within 30 days of receiving an executed copy of
the requested modification.**

  -------------------- ----------------------------------------------------
  **CONTRACTOR NAME**       

  **CONTRACT#**             

  **ADDRESS1**              

  **ADDRESS2**              

  **CITY/STATE/ZIP**        

  **PHONE**                 

  **EMAIL**                 

  **DATE SUBMITTED TO       
  VA-NAC**             
  -------------------- ----------------------------------------------------

Provide the following information for **PRICE DECREASE**

+------------+------------------+-------------------------------------+
| **         | **REQUIREMENT**  | **COMMENTS**                        |
| CONTRACTOR |                  |                                     |
| C          |                  |                                     |
| HECKLIST** |                  |                                     |
+------------+------------------+-------------------------------------+
| COMPLETE   | SPECIAL ITEM     |                                     |
|            | NUMBER (SIN)     |                                     |
| INCOMPLETE | CATEGORY(IES)    |                                     |
+------------+------------------+-------------------------------------+
| COMPLETE   | REASON FOR PRICE | Voluntary, to Government only       |
|            | REDUCTION        |                                     |
| INCOMPLETE |                  | Granted **more favorable pricing**  |
|            |                  | than that contained in the          |
|            |                  | commercial catalog, pricelist, or   |
|            |                  | other document upon which the       |
|            |                  | contract award was predicated       |
|            |                  |                                     |
|            |                  | Granted **more favorable            |
|            |                  | discounts/terms & conditions** than |
|            |                  | those contained in the catalog,     |
|            |                  | pricelist, or other document upon   |
|            |                  | which the contract award was        |
|            |                  | predicated                          |
|            |                  |                                     |
|            |                  | Granted special discounts to the    |
|            |                  | tracking that formed the basis of   |
|            |                  | award. This change disturbs the     |
|            |                  | awarded ratio.                      |
+------------+------------------+-------------------------------------+
| COMPLETE   | PRICE REDUCTION  | PERMANENT Price Reduction           |
|            |                  |                                     |
| INCOMPLETE |                  | TEMPORARY Price Reduction           |
|            |                  |                                     |
|            |                  | > Date Price Reduction Expires:     |
|            |                  | >                                   |
+------------+------------------+-------------------------------------+
| COMPLETE   | DATED COMMERCIAL | Provide a copy of the applicable    |
|            | PRICELIST        | catalog, pricelist, contractor      |
| INCOMPLETE |                  | bulletin, letter, or customer       |
|            |                  | agreement that details the          |
| NA         |                  | effective date, duration, and terms |
|            |                  | & conditions of the price           |
|            |                  | reduction.                          |
+------------+------------------+-------------------------------------+
| COMPLETE   | PRICE INCREASE   | Include a spreadsheet including the |
|            | PROPOSAL         | following information:              |
| INCOMPLETE |                  |                                     |
|            |                  | SIN#                                |
|            |                  |                                     |
|            |                  | Item#                               |
|            |                  |                                     |
|            |                  | Product Description                 |
|            |                  |                                     |
|            |                  | Quantity/Unit of Measure            |
|            |                  |                                     |
|            |                  | Previous Commercial List Price      |
|            |                  |                                     |
|            |                  | Current Commercial List Price       |
|            |                  |                                     |
|            |                  | Current FSS Pricing                 |
|            |                  |                                     |
|            |                  | Proposed NET FSS Price              |
|            |                  |                                     |
|            |                  | Previous Tracking Customer Price    |
|            |                  |                                     |
|            |                  | Current Tracking Customer Price     |
|            |                  |                                     |
|            |                  | Awarded FSS Tracking Customer Ratio |
+------------+------------------+-------------------------------------+

**AUTHORIZED REPRESENTATIVE DATE**

APPROVED APPROVED AS AMENDED DISAPPROVED

**CONTRACTING OFFICER DATE**

**EFFECTIVE DATE OF MODIFICATION**

**NOTE**: The effective date of the modification will be determined at
the time of approval of the request by the Contracting Officer.
**[Effective dates will be assigned as either the 1st or 15th of the
month.]{.underline}**

**Contractors are reminded that they must update their NAC-CM database
and GSA Advantage! files and provide the CO with an updated paper
pricelist for approval within 30 days of receiving an executed copy of
the requested modification.**

  -------------------- ----------------------------------------------------
  **CONTRACTOR NAME**       

  **CONTRACT#**             

  **ADDRESS1**              

  **ADDRESS2**              

  **CITY/STATE/ZIP**        

  **PHONE**                 

  **EMAIL**                 

  **DATE SUBMITTED TO       
  VA-NAC**             
  -------------------- ----------------------------------------------------

Provide the following information for **TRACKING CUSTOMER CHANGE**

+------------+------------------+-------------------------------------+
| **         | **REQUIREMENT**  | **COMMENTS**                        |
| CONTRACTOR |                  |                                     |
| C          |                  |                                     |
| HECKLIST** |                  |                                     |
+------------+------------------+-------------------------------------+
| COMPLETE   | SPECIAL ITEM     |                                     |
|            | NUMBER (SIN)     |                                     |
| INCOMPLETE | CATEGORY(IES)    |                                     |
+------------+------------------+-------------------------------------+
| COMPLETE   | COVER LETTER     | Explain in detail why the proposed  |
|            |                  | Tracking Customer or Category of    |
| INCOMPLETE |                  | Customer (TC) is an appropriate     |
|            |                  | customer in terms of ensuring the   |
|            |                  | Government price/discount remains   |
|            |                  | representative of market prices and |
|            |                  | will continue to benefit from       |
|            |                  | positive price changes.             |
+------------+------------------+-------------------------------------+
| COMPLETE   | COMMERCIAL SALES | Submit a spreadsheet that includes  |
|            | PRACTICE (CSP)   | the following information:          |
| INCOMPLETE | INFO             |                                     |
|            |                  | SIN#                                |
|            |                  |                                     |
|            |                  | Item#                               |
|            |                  |                                     |
|            |                  | Product Description                 |
|            |                  |                                     |
|            |                  | Commercial List Price               |
|            |                  |                                     |
|            |                  | MFC Name                            |
|            |                  |                                     |
|            |                  | MFC Discount                        |
|            |                  |                                     |
|            |                  | MFC Net Price                       |
|            |                  |                                     |
|            |                  | Proposed Government Discount off    |
|            |                  | List Price                          |
|            |                  |                                     |
|            |                  | Net FSS Price                       |
|            |                  |                                     |
|            |                  | Awarded Tracking Customer Ratio     |
|            |                  |                                     |
|            |                  | Proposed Tracking Customer          |
|            |                  |                                     |
|            |                  | % Discount off List Price           |
|            |                  |                                     |
|            |                  | TC Net Price                        |
|            |                  |                                     |
|            |                  | TC Sales (12 months)                |
+------------+------------------+-------------------------------------+
| COMPLETE   | QUANTITY         | Identify any proposed additional    |
|            | DISCOUNTS        | quantity discounts offered to the   |
| INCOMPLETE |                  | Government                          |
|            |                  |                                     |
|            |                  |                                     |
+------------+------------------+-------------------------------------+
| COMPLETE   | ADDITIONAL       | Identify any proposed additional    |
|            | DISCOUNTS        | discounts/concessions, including    |
| INCOMPLETE |                  | prompt payment discounts, annual    |
|            |                  | rebates, etc. offered to your       |
|            |                  | commercial customers                |
|            |                  |                                     |
|            |                  |                                     |
+------------+------------------+-------------------------------------+

+------------+------------------+-------------------------------------+
| **         | **REQUIREMENT**  | **COMMENTS**                        |
| CONTRACTOR |                  |                                     |
| C          |                  |                                     |
| HECKLIST** |                  |                                     |
+------------+------------------+-------------------------------------+
| COMPLETE   | PRODUCT          | Product was added at:               |
|            | INFORMATION      |                                     |
| INCOMPLETE |                  | > TIME OF AWARD                     |
|            |                  | >                                   |
|            |                  | > MODIFICATION#                     |
|            |                  | >                                   |
|            |                  | > MODIFICATION EFFECTIVE DATE       |
+------------+------------------+-------------------------------------+
| COMPLETE   | COMMENTS         |                                     |
|            |                  |                                     |
| INCOMPLETE |                  |                                     |
+------------+------------------+-------------------------------------+

**AUTHORIZED REPRESENTATIVE DATE**

APPROVED APPROVED AS AMENDED DISAPPROVED

**CONTRACTING OFFICER DATE**

**EFFECTIVE DATE OF MODIFICATION**

**NOTE**: The effective date of the modification will be determined at
the time of approval of the request by the Contracting Officer.
**[Effective dates will be assigned as either the 1st or 15th of the
month.]{.underline}**

**Contractors are reminded that they must update their NAC-CM database
and GSA Advantage! files and provide the CO with an updated paper
pricelist for approval within 30 days of receiving an executed copy of
the requested modification.**

  -------------------- ----------------------------------------------------
  **CONTRACTOR NAME**       

  **CONTRACT#**             

  **ADDRESS1**              

  **ADDRESS2**              

  **CITY/STATE/ZIP**        

  **PHONE**                 

  **EMAIL**                 

  **DATE SUBMITTED TO       
  VA-NAC**             
  -------------------- ----------------------------------------------------

Provide the following information for **ADMINSTRATIVE/OTHER CHANGE**

+------------+------------------+-------------------------------------+
| **         | **REQUIREMENT**  | **COMMENTS**                        |
| CONTRACTOR |                  |                                     |
| C          |                  |                                     |
| HECKLIST** |                  |                                     |
+------------+------------------+-------------------------------------+
| COMPLETE   | SPECIAL ITEM     |                                     |
|            | NUMBER (SIN)     |                                     |
| INCOMPLETE | CATEGORY(IES)    |                                     |
+------------+------------------+-------------------------------------+
| COMPLETE   | REASON FOR       | Change of Address                   |
|            | MODIFICATION     |                                     |
| INCOMPLETE |                  | Item Description Change             |
|            |                  |                                     |
|            |                  | Item Code Change                    |
|            |                  |                                     |
|            |                  | Add/Delete Contract Administrator   |
|            |                  |                                     |
|            |                  | Warranty Terms                      |
|            |                  |                                     |
|            |                  | Shipping Lead Times                 |
|            |                  |                                     |
|            |                  | Add/Delete Distributor              |
|            |                  |                                     |
|            |                  | Other                               |
+------------+------------------+-------------------------------------+
| COMPLETE   | DOCUMENTATION    | Provide all appropriate             |
|            |                  | documentation related to your       |
| INCOMPLETE |                  | request.                            |
+------------+------------------+-------------------------------------+

**AUTHORIZED REPRESENTATIVE DATE**

APPROVED APPROVED AS AMENDED DISAPPROVED

**CONTRACTING OFFICER DATE**

**EFFECTIVE DATE OF MODIFICATION**

**NOTE**: The effective date of the modification will be determined at
the time of approval of the request by the Contracting Officer.
**[Effective dates will be assigned as either the 1st or 15th of the
month.]{.underline}**

**Contractors are reminded that they must update their NAC-CM database
and GSA Advantage! files and provide the CO with an updated paper
pricelist for approval within 30 days of receiving an executed copy of
the requested modification.**