PGI Part 253 - FORMS

PGI 253.209 CONTRACTOR QUALIFICATIONS

PGI 253.2 -PRESCRIPTION OF FORMS

PGI 253.204 Reserved

PGI 253.208 Required sources of supplies and services.

PGI 253.208-1 DD Form 448, Military Interdepartmental Purchase Request.

PGI 253.208-2 DD Form 448-2, Acceptance of MIPR.

PGI 253.213 Simplified acquisition procedures (SF's 18, 30, 44, 1165, 1449, and OF's 336, 347, and

348).

PGI 253.213-70 Completion of DD Form 1155, Order for Supplies or Services.

PGI 253.215 Contracting by negotiation.

PGI 253.215-70 DD Form 1547,Record of Weighted Guidelines Application.

PGI 253.219 Small Business Programs.

PGI 253.219-70 DD Form 2579,Small Business Coordination Record.

PGI 253.3 -ILLUSTRATION OF FORMS

Parent topic: PGI Defense Federal Acquisition Regulation

PGI 253.209 CONTRACTOR QUALIFICATIONS

NO CURRENT PGI TEXT

PGI 253.2 -PRESCRIPTION OF FORMS

PGI 253.204 Reserved

PGI 253.208 Required sources of supplies and services.

PGI 253.208-1 DD Form 448, Military Interdepartmental Purchase Request.

(a) Use the DD Form 448 as prescribed in PGI 208.70 .

(b) Prepare MIPR information in uniform contract format when possible. Overprint of fixed repetitive
information is authorized.

(c) Instructions for completion of DD Form 448.

(1) BLOCK 5—MIPR NUMBER. Number the MIPR by using—

(i) The requiring department identification code as prescribed in DoD 4000.25-6-M, Department of

Defense Activity Address Directory (DoDAAD);

(ii) The last digit of the fiscal year; and

(iii) The number of the particular MIPR (numbered consecutively by the requiring activity).

(2) BLOCK 6—AMEND NO. Assign a suffix number. Assign amendments of the same MIPR

consecutive suffix numbers.

(3) BLOCK 9.

(i) Conduct interdepartmental screening of items in accordance with FAR 8.001. Requisition items

which are available from stocks of other departments as follows:

(A) Obtain items within the scope of MILSTRIP (see DoD 4000.25-1-M, Military Standard

Requisitioning and Issue Procedures (MILSTRIP)) by use of DD Form 1348 (Single Line Item

Requisition System Document (Manual), DoD))/1348M (Single Line Item Requisition System

Document, DoD (Mechanical)).

(B) Obtain items not covered by MILSTRIP using DD Form 1149, Requisition and Invoice/Shipping

Document.

(C) If, after receipt of a MIPR, it is determined the requested items are available from stock, the

acquiring department shall use the MIPR to obtain the item.

(ii) Normally restrict a MIPR to one major end item, including its required spare parts, ground

support equipment, and similar related items. For other than major end items, limit MIPRs to items

within a single Federal supply class when possible.

(4) BLOCK 10.

(i) Delivery Schedules.

(A) The requiring department must clearly state the required time of delivery or performance in

each MIPR, taking into consideration the normal administrative lead time of the particular

commodity. Delivery and performance schedules on MIPRs must be realistic (see FAR Subpart 11.4).

If the acquiring department cannot accept the delivery schedule in the MIPR, the acquiring

department will note that on DD Form 448-2, Acceptance of MIPR. Changes in the requested

delivery schedule must be made by MIPR amendment.

(B) When a short delivery schedule is mandatory, the requiring department shall mark the MIPR

“URGENT” in bold letters and provide justification for the marking.

(ii) Requiring activities must provide MILSTRIP requisition data prescribed in Appendix B of the

MILSTRIP Manual for each line item which is to be delivered to each “ship to” address. Repetitive

data applicable to all lines on the MIPR may be overprinted.
(iii) The requiring activity will furnish estimated weight, cube, and dimensions for each line item or a

statement explaining why these data are not available.

(iv) The requiring activity shall include the name and telephone number of an individual who is

thoroughly familiar with the MIPR, its attachments, and technical requirements.

(v) Prepare attachments to MIPRs in sufficient numbers so that each copy of a MIPR submitted to

the acquiring department is complete with a copy of all attachments. “Ship To and Mark For”

addresses in shipping instructions must include the clear text identification and DoDAAD code if

assigned.

(5) BLOCK 12—TRANSPORTATION ALLOTMENT. Enter allotment data for transportation of

supplies at Government expense if appropriate.

(6) BLOCK 13—MAIL INVOICES TO. Use this block to identify the name and address of the office to

receive invoices and make payment.

(i) Complete the block only if—

(A) The resulting contract is not to be paid by the Defense Finance and Accounting Service; and

(B) The office to receive invoices and make payment is known at the time of preparation of the

MIPR.

(ii) If payment is to be made by an office designated to receive invoices, also enter the DoDAAD code

of that office.

(iii) If payment is to be made by an office other than the office to which the invoice is to be mailed,

include the name, address, and DoDAAD code of the payment office as an attachment to the MIPR.

(iv) If multiple offices are to receive invoices and make payment, include the names and addresses of

those offices as an attachment to the MIPR. Also include the DoDAAD code of each payment office.

(v) Whenever the payment office is included in an attachment, include a reference to the attachment

in this block.

(vi) If the names and addresses of invoicing and payment offices are provided the acquiring

department after submission of the MIPR, the requiring department also must provide the DoDAAD

code for each payment office.

(7) BLOCK 14. Enter allotment data for the acquisition of supplies. Enter each citation in Item 14 in

the appropriate space as follows:

(i) Accounting Classification Reference Number (ACRN). If the ACRN procedures of PGI 204.7107

are used in the MIPR to relate allotment data to the MIPR item or delivery, enter the ACRN for each

fund citation. (The acquiring department, when preparing the contract, is not required to use the

ACRN assigned to a fund citation in the MIPR.)

(ii) Appropriation. Enter the ten positions as follows:

(A) First and second - Treasury Department number identifying the department or agency to which

the appropriation applies or has been transferred.

(B) Third and fourth - Treasury Department number identifying the department or agency from
which an appropriation has been transferred; leave blank if no transfer is involved.

(C) Fifth and sixth - Identify the appropriation fiscal year. For multiple-year appropriations, the fifth

position shall be the last digit of the first year of availability, and the sixth position shall be the last

digit of the final year of availability. For annual appropriations, the fifth position shall be blank, and

the sixth position shall be the last digit of the fiscal year. For no-year (continuing) appropriations,

the fifth position shall be blank, and the sixth position shall be “X.”

(D) Seventh through tenth - Treasury Department appropriation serial number.

(iii) Limit/Subhead. Up to four characters; if less than four characters, leave empty spaces blank.

(iv) Supplemental Accounting Classification Data. Not to exceed 36 characters. Enter in accordance

with departmental or agency regulations.

(v) Accounting Station. Enter the six character DoDAAD code of the accounting station (not used

with Navy and Marine Corps funds).

(vi) Amount. Enter the amount for each fund citation if more than one allotment is cited.

(vii) Additional Citations. If space is required for additional fund citations, include as an attachment

and reference the attachment on the form.

(d) When preparing a MIPR amendment, always fill out the basic information in Blocks 1 through 8.

Fill out only those other blocks which vary from the data shown on the basic MIPR or a prior

amendment. Insert “n/c” in items where there is no change.

(e) Change of a disbursing office cited on a DoD funded MIPR does not require a MIPR amendment

when the resultant contract is assigned for administration to the Defense Contract Management

Agency. The administrative contracting office may issue an administrative contract modification,

copies of which will be provided to the contracting officer for transmittal to the requiring activity.

(f) Signed or official record copies of MIPRs, and any amendments, shall be distributed electronically

using both of the following methods:

(1) Indexed Portable Document Format files shall be manually uploaded or sent via the Global

Exchange system (GEX) to the Electronic Data Access (EDA) (http://eda.ogden.disa.mil) system to

provide a human-readable copy.

(2) Electronic data files shall be sent via the GEX in Department of Defense Purchase Request Data

Standard Extensible Markup Language (XML) format.

PGI 253.208-2 DD Form 448-2, Acceptance of MIPR.

(a) Use the DD Form 448-2 as prescribed in PGI 208.70 .

(b) Instructions for completion of DD Form 448-2. (Complete only the applicable blocks.)

(1) BLOCK 6. Check the specific terms under which the MIPR is being accepted.

(2) BLOCK 7. If any one of the MIPR line items is not accepted, check Block 7 and record the

affected MIPR line item number and reason in Block 13.
(3) BLOCKS 8 AND 9. Use Blocks 8 and 9 only—

(i) When Block 6c acceptance is indicated (indicate the MIPR line item numbers that will be provided

under each method of financing in Blocks 8a and 9a, respectively); or

(ii) If quantities or estimated costs cited in a MIPR require adjustment (list the affected MIPR line

item numbers together with the adjusted quantities or estimated costs in the columns provided

under Blocks 8 and 9, as appropriate).

(4) BLOCK 10. Whenever a MIPR is accepted in part or in total under Category II funding, forecast

the estimated date of contract award.

(5) BLOCK 11. Enter the total amount of funds required to fund the MIPR items, as accepted.

(6) BLOCK 12.

(i) Complete this block only in those cases where the amount recorded in Block 11 is not in

agreement with the amount recorded in Block 5. This will serve either—

(A) As a request to the requiring department to issue a MIPR amendment to provide the additional

funds; or

(B) Authority for the requiring department to withdraw the available excess funds.

(ii) When funds of two or more appropriations are involved, provide proper breakdown information

in Block 13.

(7) BLOCK 13. Use this block to record—

(i) Justification, by MIPR line item, for any additional funds required;

(ii) Explanation for rejection of MIPR whether in part or in total;

(iii) Appropriation and subhead data cited on the MIPR; and

(iv) Other pertinent data.

(c) Complete a DD Form 448-2 for all MIPR amendments involving an adjustment of funds or

delivery schedule, or if requested by the requiring department.

(d) Unless otherwise agreed, provide the requiring department an original and three copies of each

DD Form 448-2.

PGI 253.213 Simplified acquisition procedures (SF's 18, 30, 44, 1165, 1449,

and OF's 336, 347, and 348).

(f)(i) Use the OF 336, or a sheet of paper, as a continuation sheet for the DD Form 1155.

Continuation sheets may be printed on the reverse of the DD Form 1155.

(ii) DD Form 1155c-1, Order for Supplies or Services (Commissary Continuation Sheet) may be used

for commissary acquisitions.
PGI 253.213-70 Completion of DD Form 1155, Order for Supplies or Services.

(a) The following instructions are mandatory if—

(1) Contract administration has been assigned outside the purchasing office; or

(2) The contractor is located in the contiguous United States or Canada.

(b) The entity codes (address codes) referenced in this subsection are codes published in—

(1) DoD Activity Address Directory (DODAAD), DoD 4000.25-6-M.

(2) Military Assistance Program Address Directory System (MAPAD), DoD 4000.25-8M.

(3) Commercial and Government Entity (CAGE) Codes Handbook H4/H8.

(c) For orders requiring payment in Canadian currency—

(1) State the contract price in terms of Canadian dollars, followed by the initials CN; e.g.,

$1,647.23CN.

(2) Indicate on the face of the order—

(i) The U.S./Canadian conversion rate in effect at the time of the award; and

(ii) The U.S. dollar equivalent of the Canadian dollar amount.

(d) When the DD Form 1155 includes FMS requirements, clearly mark “FMS Requirement” on its

face. Specify within the order each FMS case identifier code by line or subline item number.

(e) Instructions for DD Form 1155 entries. (Instructions apply to purchase orders, delivery orders,

and calls, except Block 2, which applies only to delivery orders and calls, and Block 12, which

applies only to purchase orders.)

BLOCK

1 Contract/Purch Order/AGREEMENT No.—Enter the Procurement Instrument Identification (PII)

number and, when applicable, the supplementary identification number for contracts, purchase

orders, and agreements as prescribed in DFARS Subpart 204.16.

2 Delivery Order/CALL No.—Enter the PII number for delivery orders/calls, when applicable, as

prescribed in DFARS Subpart 204.16.

3 Date of Order/CALL—Enter the four-position numeric year, three-position alpha month, and twoposition numeric day.

4 Requisition/Purch Request No.—Enter the number authorizing the purchase. When the number

differs by line item, list it in the Schedule and annotate this block, “See Schedule.”

5 PRIORITY—Enter the appropriate Program Identification Code as identified in Schedule I to the

Defense Priorities and Allocations System Regulation.

6 Issued By—Enter the name and address of the issuing office. In the code block, enter the DoDAAD
code for the issuing office. Directly below the address, enter: Buyer/Symbol: followed by the buyer's

name and routing symbol. Directly below the buyer/symbol, enter: Phone: followed by the buyer's

phone number and extension.

7 Administered By—Enter the name and address of the contract administration activity. On purchase

orders retained by purchasing offices for administration, mark this block, “See Block 6.” Enter in the

code block the DODAAD code of the contract administration activity. In the lower right or left-hand

corner, enter the criticality designator code from FAR 42.1105.

8 Delivery FOB—Check the applicable box.

9 Contractor—

(1) Enter the full business name and address of the contractor. Enter in the first code block, the

CAGE code of the contractor.

(2) If it is known that all the work covered by the order is to be performed at an address different

from the address represented by the contractor's code, and any contract administration function will

be required at that facility, enter in the facility code block the organizational entity code for that

facility, i.e., H8-1/H8-2 code for a non-Government entity or DODAAD code for a Government entity.

(Use DODAAD codes only to indicate “performed at” locations for orders specifying services at a

Government location.) If it is known that multiple facilities are involved, enter the codes for all

facilities at which work is to be performed, including the contractor's code if work is performed at

that address, in the Optional Form 336 Continuation Sheet and mark the facility code block with

“See Schedule.”

10 Deliver to FOB Point by (Date)—If a single date of delivery applies to the entire order, enter date

in this block. List multiple delivery dates in the schedule and mark this block “See Schedule.”

11 Mark If Business—Check all applicable blocks.

12 Discount Terms—Enter the discount for prompt payment in terms of percentages and

corresponding days. Express the percentages in whole numbers and decimals, e.g., 3.25% - 10 days;

0.50% - 20 days.

13 Mail Invoices To THE ADDRESS IN BLOCK—Enter a reference to the block number containing

the address to which invoices are to be mailed. When not in Block 6, 7, 14, or 15, insert in Block 13,

“See Schedule.”

14 Ship To—If a single ship-to point applies to the entire order, enter the name and address of that

point in this block and a DODAAD code in the code block. For FMS shipments, enter the MAPAD

code in the code block and an instruction for the contractor to contact the transportation office of

the administering activity to obtain a name and a shipping address. Enter multiple ship-to points in

the Schedule and mark this block, “See Schedule.”

15 Payment Will Be Made By—Enter the name and address of the activity making payment. Enter in

the code block, the DODAAD code of the paying activity. When a purchase card is used for payment,

enter “CRCARD” in the code block.

16 Type of Order—Check the appropriate box. If a purchase order:

(1) Identify the type of quotation, e.g., oral, letter, e-mail, on which the order is based.
(2) Check the box when acceptance of the purchase order is required and enter the number of

copies of the order to be returned to the issuing office.

17 Accounting and Appropriation Data/Local Use—Enter the accounting classification and the

accounting classification reference number(s) in accordance with DFARS 204.7107.

18 Item No.—Enter an item number for each item of supply or service in accordance with DFARS

Subpart 204.71.

19 Schedule of Supplies/Services—The Schedule contains several elements of data. The order and

arrangement of data in the Schedule is mandatory for purchase and delivery orders assigned to the

Defense Contract Management Agency or the military departments for administration and is

encouraged for all orders.

(1) National Stock Number (NSN)—Total item quantity for the line or subline item number followed

by the appropriate national stock number or the word “none” if an NSN has not been assigned. On

the same line and adjacent to NSN, enter the words “Total Item Quantity.” This phrase is used in

conjunction with the total quantity, unit of issue, unit price, and dollar amount of the stock number

or item cited (see entries for Blocks 20, 21, 22, and 23).

(2) Item Identification—Enter first the most descriptive noun or verb of the supplies or services to be

furnished, supplemented by additional description as prescribed in FAR Part 10. If multiple

accounting classifications apply to the contract, enter the accounting classification reference

number.

(3) Quantity Variance—Enter the quantity variance permitted for the line item in terms of

percentages, indicating whether the percentage is plus or minus and if applicable to each

destination.

(4) Inspection/Acceptance—Enter the point at which inspection/acceptance will take place.

(5) Preservation and Packaging—Enter the preservation requirements for the item described. These

requirements may be expressed in terms of MIL-STD-2073-1, DoD Material Procedures for

Development and Application of Packaging Requirements, and MIL-STD-2073-2, Packaging

Requirements, codes. They may also be expressed by reference to applicable specifications.

(6) Packing—When required, enter the packing level designator and specification, standard, or

document in which the requirements are stated or state the specific requirements.

(7) Unitization—When desired by the requiring activity, a requirement for cargo unitization for a

particular destination should be specified for shipments involving two or more shipping containers

having an aggregate total of not less than 20 cubic feet or 200 pounds.

(8) Ship To—Enter the DODAAD or MILSCAP H8-1/H8-2 (cage) as appropriate for the entity code of

the ship-to point on the first line and the corresponding name and address on succeeding lines. If

multiple accounting classifications apply to the same line or subline item, enter the accounting

classification reference number. When several items are to be shipped to the same point, the code

will be listed; but it will not be necessary to repeat the address.

(9) Delivery Date—When multiple delivery dates apply, enter the required date of delivery on the

same line with ship-to code.

(10) Mark For—Enter the DODAAD or MILSCAP H8-1/H8-2 (cage) as appropriate for the entity code
on the first line and name and address of the ultimate recipient of the supplies and services on

succeeding lines.

20 Quantity Ordered/Accepted—Enter the total quantity ordered for the line item. If applicable,

enter the breakdown on quantities for each ship-to point within the line item.

21 Unit—Enter the unit of measure applicable to the line item.

22 Unit Price—Enter the unit price applicable to the line item.

23 Amount—Enter the extended dollar amount (quantity x unit price) for each line item.

24 Contracting/Ordering Officer—Enter the contracting/ordering officer's signature.

25 Total Amount—Enter the total dollar amount for all line items on the order.

26 thru 42 These blocks are used in the receiving and payment functions. Procedures for making

entries are prescribed by the respective departments.

PGI 253.215 Contracting by negotiation.

PGI 253.215-70 DD Form 1547,Record of Weighted Guidelines Application.

(a) Use the DD Form 1547 as prescribed in DFARS 215.404-70 and 215.404-71.

(b) General instructions.

(1) Report amounts as they relate to the price of the contract action without regard to funding status

(e.g., amounts obligated).

(2) Express all dollar values to the nearest whole value (e.g., $200,008.55 = $200,009).

(3) Do not express percentages beyond the nearest thousandth (e.g., interest rate—8.257%).

(4) If the contracting office is exempt from reporting to the DoD management information system on

profit and fee statistics (see PGI 215.404-76), do not complete Block 1, 4, 5, 6, 7, 8, 9, 10, 11, or 12.

(5) Report an option amount for additional quantities as a separate contract action when exercised.

(6) Even though fixed-price type contract actions are negotiated on the basis of total price, prepare

the negotiation summary portion of the DD Form 1547 showing the contracting officer's best

estimates of cost and profit.

(7) For indefinite-delivery type contracts, prepare a consolidated DD Form 1547 for annual

requirements expected to exceed the certified cost or pricing data threshold.

(8) Prepare a consolidated DD Form 1547, if possible, when multiple profit rates apply to a single

negotiation.

(c) Specific instructions for completion of DD Form 1547.

(1) BLOCK 1—REPORT NO. Enter the four-digit local control number followed by a dash and the last
two digits of the fiscal year (e.g., 0004-06 for 4th action in fiscal year 2006). Each field contracting

office participating in profit reporting shall establish a control system for consecutively numbering

completed DD Forms 1547. Always start with 0001 at the beginning of each fiscal year and always

use four digits. This number will identify the specific DD Form 1547 in DoD's management

information system and will be used for follow-up actions.

(2) BLOCK 2—BASIC PROCUREMENT INSTRUMENT IDENTIFICATION NO. Enter the identifying

contract number assigned per DFARS Subpart 204.16.

(3) BLOCK 3—SPIIN. Enter the supplemental procurement instrument identification number for

supplemental agreements or other modifications, assigned per DFARS Subpart 204.16.

(4) BLOCK 4—DATE OF ACTION.

(i) Year. Enter the last two digits of the year the action was negotiated (e.g., 06 for 2006).

(ii) Month. Enter the two-digit number for the month the action was negotiated (e.g., 09 for

September).

(5) BLOCK 5—CONTRACTING OFFICE CODE. Enter the code assigned the contracting office per

DoD Procurement Coding Manual, Volume III.

(6) BLOCK 6—NAME OF CONTRACTOR. Enter the contractor's name (including division name).

(7) BLOCK 7—DUNS NUMBER. Enter the contractor establishment code number.

(8) BLOCK 8—FEDERAL SUPPLY CODE.

(9) BLOCK 9—DOD CLAIMANT PROGRAM.

(10) BLOCK 10—CONTRACT TYPE CODE. Enter the appropriate code—

Description Code

FPR (all types)

FPI (all types)

FFP

FP(E)

CPFF

CPIF (all types)

A

L

J

K

U

V

(11) BLOCK 11—TYPE EFFORT. Enter the appropriate code—

Description Code
Manufacturing

Research and

Development

Services

1

2

3

(12) BLOCK 12—USE CODE. Enter the appropriate code for use of the weighted guidelines

method—

Description Code

Standard weighted guidelines method (DFARS 215.404-71 -2(c)(1)) 2

Alternate structured approach (DFARS 215.404-73) 4

Modified weighted guidelines approach (DFARS 215.404-72) 5

Technology incentive (DFARS 215.404-71 -2(c)(2)) 6

(13) BLOCKS 13 through 20—COST CATEGORY OBJECTIVE. Enter the prenegotiation objectives.

Include contractor independent research and development/bid and proposal in the general and

administrative expenses in Block 19.

(14) BLOCKS 21 through 29—WEIGHTED GUIDELINES PROFIT FACTORS. Enter the amounts

determined in accordance with DFARS 215.404-71 or 215.404-72. This section is not required to be

completed when using an alternate structured approach (DFARS 215.404-73).

(15) BLOCK 30—TOTAL PROFIT OBJECTIVE. Enter the total of Blocks 23, 24, 25, 27, 28, and 29.

This section is not required to be completed when using an alternate structured approach (DFARS

215.404-73).

(16) BLOCKS 31 through 35—NEGOTIATION SUMMARY. Complete as indicated on the form. For

fixed-price type contracts negotiated on a total price basis, enter the contracting officer's best

estimates of cost and profit. When using an alternate structured approach, see DFARS

215.404-73(b)(2) for offsets.

(17) BLOCKS 36 through 39—CONTRACTING OFFICER APPROVAL. The contracting officer shall

sign the form. Include a complete (with area code) commercial telephone number to facilitate any

follow-up actions.

(18) BLOCKS 96 through 99—OPTIONAL USE. Complete in accordance with department/agency

procedures, if any.
PGI 253.219 Small Business Programs.

PGI 253.219-70 DD Form 2579,Small Business Coordination Record.

(a) Use the DD Form 2579 as prescribed in DFARS 219.201 (c)(10)(B).

(b) General instructions.

(1) The Contracting Officer is responsible for the coordination and completion of the form.

(2) Coordination on this form is not required when the agency will satisfy a requirement through the

use of a mandatory source listed at FAR 8.002 or FAR 8.003.

(c) Specific instructions for completion of DD Form 2579.

(1) BLOCK 1—CONTROL NO. Reserved for use by the Small Business Professional to create a

unique identification number for each coordination record.

(2) BLOCK 2—PURCHASE REQUEST/REQUISITION NO. Locally assigned purchase

request/requisition number.

(3) BLOCK 3—TOTAL ESTIMATED VALUE. Enter the total estimated value for the acquisition,

including all options. For multiple award task or delivery order contracts, enter the total estimated

value of the entire acquisition including all orders expected to be awarded.

(4) BLOCKS 4a and 4b:

(i) Block 4a—PROCUREMENT INSTRUMENT IDENTIFIER (PIID). Enter the PIID assigned to the

solicitation, contract, or order in Block 4a. (FAR 4.1601, DFARS 204.1601).

(ii) Block 4b—INDEFINITE DELIVERY VEHICLE (IDV) PIID. If applicable, enter the PIID assigned to

the IDV against which the solicitation or order identified in Block 4a is issued.

(5) BLOCK 5—MODIFICATION/AMENDMENT NUMBER (MOD/AMDMT No.). Enter the contract or

order modification number or solicitation amendment number. (FAR 4.1601, DFARS 204.1601).

(6) BLOCKS 6a through 6e—CONTRACTING OFFICER NAME, DOD ACTIVITY ADDRESS CODE

(DODAAC), OFFICE SYMBOL, EMAIL ADDRESS, PHONE NO. Enter the appropriate information in

Blocks 6a through 6e.

(7) BLOCKS 7a through 7d:

(i) BLOCK 7a—ITEM and/or SERVICE DESCRIPTION. Enter description of planned acquisition,

including quantity, unique delivery requirements, and other descriptors. For services, include the

type of service and place of performance, and attach a copy of the Performance Work Statement

(PWS), Statement of Work (SOW), Statement of Objectives (SOO), or other specifications and

statements as appropriate.

(ii) BLOCK 7b—PRODUCT OR SERVICE CODE (PSC). For the Product and Service Codes Manual, go

to http://acquisition.gov.

(iii) BLOCK 7c—NORTH AMERICAN INDUSTRY CLASSIFICATION (NAICS) CODE. For the NAICS
codes and definitions, go to http://www.census.gov/eos/www/naics.

(iv) BLOCK 7d—SMALL BUSINESS SIZE STANDARD. For the applicable small business size

standard, go to http://www.sba.gov/content/table-small-business-size-standards.

(8) BLOCK 8—PERIOD OF PERFORMANCE/DELIVERY DATES. Enter the estimated beginning and

end dates.

(9) BLOCK 9—PURPOSE OF COORDINATION. Check one box indicating the purpose of the action

being reviewed: Initial Coordination, Withdrawal (see FAR 19.506), or a Change to the form. Note:

Any significant change in the acquisition strategy or plan described on this form will require

reevaluation by the Small Business Professional and the Small Business Administration (SBA)

Procurement Center Representative (PCR), if applicable.

(10) BLOCKS 10a through 10j—RECOMMENDATION. Check all that apply, e.g., a small business

set-aside could also be a multiple-award. For Blocks 10c through 10d, attach justification if

applicable in accordance with FAR 19.1306(a), and 19.1406(a), respectively.

(11) BLOCKS 11a through 11c:

(i) BLOCK 11a—ACQUISITION PLAN/MARKET RESEARCH. Attach the written acquisition plan (FAR

7.104(d)), if required, and the results of market research, including any resulting justification and

approval (FAR 6.3) or sole source/brand name justification (FAR 13.106 or 13.501). Include findings

that demonstrate efforts to locate qualified small business sources e.g., sources sought (FAR 5.205),

requests for information synopses, or waivers to the nonmanufacturer rule (FAR 19.5) and attach

additional pages as necessary).

(ii) BLOCK 11b—SYNOPSIS REQUIRED. Check “Yes” or “No.” If “No,” provide explanation and the

exception under FAR 5.202, if applicable.

(iii) BLOCK 11c—SMALL BUSINESS PROGRESS PAYMENTS. Check “Yes” or “No” (DFARS

232.501-1(a)).

(12) BLOCK 12—CONSOLIDATED OR BUNDLED. Select either “Consolidated” or “Bundled,” and

check “Yes” or “No” for each. If “Yes,” attach required documentation for consolidation or bundling

(FAR 7.107).

(13) BLOCK 13—SUBCONTRACTING PLAN REQUIRED. Check “Yes” or “No.” For recommendations

10g, 10h, or 10i, or if Block 12 recommendation is “Yes,” specify actions that will be taken to

maximize small business participation. Consider requirements of FAR 19.7, acquisition history,

anticipated subcontracting goals, market research to identify small business capability at the

subcontract level, source selection evaluation factor for small business utilization (DFARS 215.304 ,

215.305), incentives, contract performance metrics, etc. State detailed objectives for subcontract

(attach additional pages as necessary).

(14) BLOCKS 14a through 14c—ACQUISITION HISTORY:

(i) BLOCK 14a—NEW REQUIREMENT. Check “Yes” or “No” and follow the applicable guidance for

each selection.

(ii) BLOCK 14b—PREVIOUSLY CONSOLIDATED OR BUNDLED. Check “Yes” or “No” for each. If

“Yes,” attach required documentation for previous acquisition.
(See FAR 7.107.)

(iii) BLOCK 14c—DETAILS OF PREVIOUS AWARD(S). For each contractor that received an award

for any portion of the immediately preceding acquisition, include the following information—

—Name and CAGE code.

—Small business socioeconomic categories of the awardee.

—PIID.

—NAICS code and size standard.

—Contract type.

—Period of performance.

—Total contract value.

—Subcontracting History. (Small business subcontracting goal achievement (CPARS and eSRS data)

and any additional small business utilization requirements included in the contract resulting from a

source selection factor used when making the previous contract award.)

(15) BLOCK 15a through 15d—CONTRACTING OFFICER SIGNATURE. Complete 15a through 15d.

Digital signature is desired.

(16) BLOCKS 16 through 16f—SMALL BUSINESS PROFESSIONAL/SMALL BUSINESS DIRECTOR

REVIEW. Complete 16 through 16f. Digital signature is desired. If “non-concur” is checked, attach

rationale or include in Block 16f, along with any other remarks. Block 16e must be completed when

any of the conditions in FAR 19.202-1(e) applies to indicate when the acquisition package was

provided to the Small Business Administration (SBA).

(17) BLOCKS 17 through 17e—SBA PROCUREMENT CENTER REPRESENTATIVE (PCR) REVIEW.

Complete 17 through 17e (see FAR 19.402(a) when a PCR is not assigned to the contracting activity

or administration office). Digital signature is desired. If “non-concur” is checked, the PCR shall

attach rationale and recommendations or include in Block 17e, along with any other remarks (see

FAR 19.402).

(18) BLOCKS 18 through18c—CONTRACTING OFFICER REVIEW. The Contracting Officer shall

complete this block if the Small Business Professional and/or the SBA PCR have “non-concurred” in

Blocks 16 and 17. Block 18c shall include the Contracting Officer’s rationale for decision. Send

copies of the completed form to the Small Business Professional and the SBA PCR within 5 working

days if rejecting the PCR’s recommendation, in accordance with FAR 19.505.

PGI 253.3 -ILLUSTRATION OF FORMS