FEDERAL SUPPLY SCHEDULE

DEPARTMENT OF VETERANS AFFAIRS

NATIONAL ACQUISITION CENTER

FEDERAL SUPPLY SERVICE (049A2-2)

PHARMACEUTICAL TEAM

P.O. BOX 76, BLDG. 37 (1^st^ AVE., 1 BLOCK NORTH OF CERMAK RD.)

HINES, ILLINOIS 60141

REQUEST FOR MODIFICATION FORM

PRICE INCREASE

For Federal Supply Schedules:

65, Part I, Section B -- Pharmaceuticals

[42-2A items ONLY]{.underline}

[PUBLIC LAW 102-585]{.underline}

[2009 UPDATE]{.underline}

Please use this form in conjunction with the Modification Clause
552.243-72 and Generic Item Modifications AS212 of your contract.

***[Please do not submit this cover page.]{.underline}***

You may submit this request for modification form(s) by scanning and
emailing to your assigned contracting officer, by faxing to (708)
786-4975 or 4974, or by submitting a hard copy via U.S. postal services
to your assigned contracting officer.

**Note**: Please note that the format has changed. Please read carefully
and follow the instructions for completing the modification
successfully. If all required material is not received, your Contracting
Officer may return your modification request with no additional action.

Company Name: **     **

Date **submitted** to VANAC: **     **

Contract No.: **V797P-      ** ­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­

Special Item Number (SIN) Category: **42-2A**

**Please indicate the type of increase requested**:

Increase to FSS/BIG4 pricing as permitted by Public Law 102-585

Increase to dual pricing as prescribed by EPA clause 552.216-70

**NOTE:** Justification and Documentation may be requested by the
Contracting Officer to determine fair and reasonable pricing before
awarding any and/or all price increase requests.

(See Economic Price Adjustment 552.216-70 in your contract.)

A)  Please complete your 2009 Public Law spreadsheet as stated in the
    instructional document:

**Public Law Instructions.doc**

[Please Note]{.underline}: The awarded tracking customer, established
ratio and calculated Federal Ceiling Price will affect your ability to
receive a price increase.

B\) Provide a dated copy of [previous and current commercial price
lists]{.underline}.

C\) Complete the following certification: ***(Please provide a signature
above printed name)***

I, [**[     ]{.underline}**]{.mark} certify that no adverse change has
occurred in the ratio between the awarded FSS price and the tracking
customer price since the award of the item.

**[PUBLIC LAW 102-585 PRICING UPDATES]{.underline}**

A\) Provide a listing of all "covered drug" NDC numbers and proposed
price changes required/permitted by Public Law 102-585.

B\) Complete the following certification: ***(Please provide a signature
above printed name)***

I, [**[     ]{.underline}**]{.mark} understand that the Public Law
calculated Federal Ceiling Price is the maximum price for an NDC and
that the Price Reduction Clause may cause the actual FSS selling price
to the Government to fall below the FCP. I have reviewed (a) my
commercial pricing and the price/discount relationship applicable to my
awarded tracking customer, and (b) the Price Reduction Clause with
regard to the maintenance of the established price/discount
relationship, and (c) I certify that the attached updated prices do not
adversely disturb the price/discount relationship established for this
FSS contract.

**PLEASE PROVIDE [AUTHORIZED]{.underline}**[^1] **SIGNATURE AND DATE
BELOW:**

[Signature of authorized Signatory]{.mark} [Date]{.mark}

**     **

Print Name and Title

***(To be completed by VA personnel)***

Approved Approved as Amended Disapproved

Signature of Contracting Officer Date Effective Date

**Prepared by:**

Signature of Contract Specialist (if applicable) Date CO Review

[^1]: An authorized signature is an individual listed in Block 6 or 7 of
    the Signatory Authority Form. No unauthorized signatures will be
    accepted.