UNIT RATE COST UNIT RATE COST

I COMPLETE PRODUCT:

Cut Sheet Forms:

A Format A: Single Leaf Form:

Up to 5-1/2 x 8-1/2" Sheet

(a) Makeready and setup charge ................. 5 123.00 615.00 103.20 516.00

(b) Running per 100 copies .................. 50 11.91 595.50 10.04 502.00

2 Printed two sides in a single ink color:

(a) Makeready and setup charge ................. 1 190.00 190.00 145.00 145.00

(b) Running per 100 copies .................. 10 14.90 149.00 10.24 102.40

3 Printing an additional ink color, per side:

(a) Makeready and setup charge ................. 1 90.00 90.00 90.00 90.00

(b) Running per 100 copies .................. 5 6.25 31.25 32.00 160.00

Format B: Single Leaf Form:

Over 5-1/2 x 8-1/2” up to and including 8-1/2 x 11”.

1 Printed one side only in a single ink color:

(a) Makeready and setup charge ................. 3 123.00 369.00 103.20 309.60

(b) Running per 100 copies .................. 30 11.91 357.30 12.55 376.50

2 Printed two sides in a single ink color:

(a) Makeready and setup charge ................. 5 190.00 950.00 145.00 725.00

(b) Running per 100 copies .................. 50 14.90 745.00 12.80 640.00

3 Printing an additional ink color, per side:

(a) Makeready and setup charge ................. 1 90.00 90.00 90.00 90.00

(b) Running per 100 copies .................. 5 6.25 31.25 32.00 160.00

B Multipart sets for Format A and B

1 2-part set:

(a) Makeready and setup charge ................. 2 150.00 300.00 125.00 250.00

(b) Running per 100 copies .................. 20 22.00 440.00 18.72 374.40

2 3-part set:

(a) Makeready and setup charge ................. 4 103.00 412.00 137.00 548.00

(b) Running per 100 copies .................. 230 48.50 11,155.00 40.74 9,370.20

3 4-part set:

(a) Makeready and setup charge ................. 2 177.00 354.00 149.00 298.00

(b) Running per 100 copies .................. 130 60.00 7,800.00 50.63 6,581.90

4 5-part set:

(a) Makeready and setup charge ................. 1 191.00 191.00 161.00 161.00

(b) Running per 100 copies .................. 10 72.00 720.00 60.74 607.40

5 6-part set:

(a) Makeready and setup charge ................. 1 205.00 205.00 210.00 210.00

(b) Running per 100 copies .................. 10 87.00 870.00 90.00 900.00

6 Printing one color on the back (same image for each part):

(a) Makeready & set up charge per set........................ 1 90.00 90.00 90.00 90.00

(b) Running per 100 sides of leaves ..................... 10 6.25 62.50 7.00 70.00

7 Printing an additional ink color (each color):

(a) Makeready & set up charge per set........................ 1 90.00 90.00 90.00 90.00

(b) Running per 100 sides of leaves ..................... 10 6.25 62.50 7.00 70.00

Program No. 1503-S Term Date of Award - February 1, 2024 through January 31, 2025. Plus up to 2 

optional years

Title: Cut Sheet Forms & Snap Sets, General Usage

ITEM 

NO. DESCRIPTION

BASIS 

OF 

AWARD

Integrated Print & 

Graphics South Elgin, IL

Provious Contractor 

Integrated Print & Graphics 

South Elgin, IL
II STOCK/PAPER:

A. Single Leaf Forms:

(a) White Writing (16 lbs.) ................................. 10 1.20 12.00 1.50 15.00

(b) Colored Writing (16 lbs.) ............................. 10 1.55 15.50 1.55 15.50

(c) White Uncoated Text (60 lbs.) ........................ 5 1.55 7.75 1.55 7.75

(d) White No. 1 Smooth-Finish Text, (70 lbs.) ........... 5 1.75 8.75 1.80 9.00

(e) White Index (110 lbs.) ......................... 15 5.50 82.50 57.62 864.30

(f) Colored Index (110 lbs.) .................................. 10 6.30 63.00 65.66 656.60

(g) White Pressure Sensitive Uncoated Label stock, (50 - 60 lbs.)... 10 0.00 0.00 75.00 750.00

B Over 5-1/2 x 8-1/2” up to and including 8-1/2 x 11”.

(a) White Writing (16 lbs.) ................................. 5 1.55 7.75 1.60 8.00

(b) Colored Writing (16 lbs.) ............................. 5 2.20 11.00 2.50 12.50

(c) White Uncoated Text (60 lbs.) ........................ 10 1.85 18.50 1.90 19.00

(d) White No. 1 Smooth-Finish Text, (70 lbs.) ........... 20 2.00 40.00 2.00 40.00

(e) White Index (110 lbs.) ......................... 30 7.20 216.00 7.00 210.00

(f) Colored Index (110 lbs.) .................................. 10 9.00 90.00 9.00 90.00

(g) White Pressure Sensitive Uncoated Label stock, (50 - 60 lbs.)... 5 0.00 0.00 65.66 328.30

B Multi-part Sets 

Per 100 Leaves (Over 5-1/2 x 8-1/2” to 8-1/2 x 11”)

(a) White Chemical Transfer Bond, CF or CB (13-17 lbs.)... 400 4.10 1,640.00 5.00 2,000.00

(b) Colored Chemical Transfer Bond, CF or CB (13-17 lbs.) 400 6.00 2,400.00 6.50 2,600.00

(c) White Chemical Transfer Bond, CFB (13-17 lbs.) 160 5.50 880.00 6.00 960.00

(d) Colored Chemical Transfer Bond, CFB (13-17 lbs.) 10 6.20 62.00 6.50 65.00

(e) White and Manila High-Finish Tag, CF, 7-1/2 point (200 lbs.) 10 12.30 123.00 13.00 130.00

III ADDITIONAL OPERATIONS:

(a) Typesetting...per each set of 20 lines of type .. 90 60.00 5,400.00 60.00 5,400.00

(b) PDF Proofs...per order............ 18 30.00 540.00 25.00 450.00

(c) Numbering per Single Leaf Form and per Multipart Set:

(1) Makeready and/or Setup ...................... per series ......... 12 35.00 420.00 35.00 420.00

(2) Running per 100 leaves for Single Leaf Forms.....per series . 20 2.30 46.00 3.00 60.00

(3) Running per 100 sets of Multipart Sets....per series 420 2.30 966.00 3.00 1,260.00

(d) Perforating/Scoring, up to 3 lines:

(1) Makeready and/or Setup ... 1 31.25 31.25 32.00 32.00

(2) Running per 100 Copies .... 10 2.45 24.50 2.50 25.00

(e) Drilling up to 3 holes per run ............. per 100 leaves . 20 0.38 7.60 1.00 20.00

(f) Changes:

(1) Marginal Changes........................................per change........ 10 9.40 94.00 0.40 4.00

(2) Minor Changes..............................................per change........ 1 60.00 60.00 60.00 60.00

(3) Major Changes..............................................per change........ 1 60.00 60.00 60.00 60.00

(g) Padding (assembling leaves into pads, stacking,

gum or gum/crash, and slicing pads apart),

includes backboards ..........................................per pad ....... 50 0.38 19.00 0.40 20.00

(h) Shrink-film packaging..................each package........ 200 0.35 70.00 0.30 60.00

(i) Authors alternations...............desktop time per hour..... 5 80.00 400.00 80.00 400.00

IV DELIVERY CHARGES:

(a) Flat rate for one carton Up to 40 lbs. ....................... 25 43.00 1,075.00 45.00 1,125.00

CONTRACTOR TOTALS $41,856.40 $41,614.35

DISCOUNT 1.00% $418.56 1.00% $416.14

DISCOUNTED TOTALS $41,437.84 $41,198.21

Abstract reviewed by: TF

Abstract prepared by: KD

Award
Program 1503-S Page 1 of 18 

Written by: TF

Reviewed by: CS

This procurement is being solicited as a small purchase Request for Quotation (RFQ). The sealed bidding 

terminology as used throughout these specifications is synonymous with their negotiated procurement 

counterparts unless specifically stated otherwise. Negotiated pursuant to 41 U.S.C. 5(1). 

U.S. GOVERNMENT PUBLISHING OFFICE

Northcentral Region 

GENERAL TERMS, CONDITIONS, AND SPECIFICATIONS

For the Procurement of 

Single Leaf Forms and Multiple-Part NCR Sets, General Usage 

as requisitioned from the U.S. Government Publishing Office (GPO) by

Various Government Departments and Agencies

Single Award

QUOTE OPENING: Quotes shall be opened at 11:00 a.m., prevailing Central Standard Time (CST), on 

January 11, 2024 for the U.S. Government Publishing Office, Northcentral Region. This will NOT be a public 

bid opening. 

QUOTE SUBMISSION: Bidders MUST submit email bids to bidsnorthcentral@gpo.gov for this solicitation. 

See also “ADDITIONAL EMAILED QUOTE SUBMISSION PROVISIONS”.

No other method of quote submission will be accepted at this time. 

The contract number “1503-S” and quote opening date “January 11, 2024” must be specified in the subject line 

of the emailed quote submission. Quotes received after “11:00 a.m. Central Standard Time” on the quote 

opening date specified above will not be considered for award. 

ADDITIONAL EMAILED QUOTE SUBMISSION PROVISIONS: The Government will not be responsible 

for any failure attributable to the transmission or receipt of the emailed bid including, but not limited to, the 

following: 

1. Illegibility of bid.

2. Emails over 10 MB may not be received by GPO due to size limitations for receiving emails.

3. The bidder’s email provider may have different size limitations for sending email; however, bidders are 

advised not to exceed GPO’s stated limit.

4. When the email bid is received by GPO, it will remain unopened until the specified bid opening time. 

Government personnel will not validate receipt of the emailed bid prior to bid opening. GPO will use the 

prevailing time (specified as the local time zone) and the exact time that the email is received by GPO’s 

email server as the official time stamp for bid receipt at the specified location. 

BIDDER’S NAME AND SIGNATURE: Unless specific written exception is taken, the bidder, by signing and 

submitting a quote, agrees with and accepts responsibility for all certifications and representations as required by 

the solicitation and GPO Contract Terms – Publication 310.2. 

When responding by email, fill out and return one copy of all pages in “SECTION 4. – SCHEDULE OF PRICES,” 

including initialing/signing where indicated. Valid electronic signatures will be accepted in
Single Leaf Forms and Multiple-Part Sets Page 2 of 18 

1503-S 

accordance with the Uniform Electronic Transactions Act, § 2. Electronic signatures must be verifiable of the 

person authorized by the company to sign quotes. 

NOTE: Bidder must use the exact quote pages in “SECTION 4. – SCHEDULE OF PRICES,” and MUST NOT

substitute their own quote formatting in their submitted quote. Substitution may result in a determination of the 

bid as non-responsive.

NOTE: Section 4.-Schedule of Prices has been revised. Other related changes from the previous specifications 

are scattered throughout. Bidders are cautioned to familiarize themselves with all provisions of these specifications 

before bidding. 

CONTRACT TERM: The term of this contract is for the period beginning February 1, 2024 and ending 

January 31, 2025 plus up to 2 optional 12-month extension period(s) that may be added in accordance with the 

“Option to Extend the Contract Term” clause in this contract.

INFORMATION: For questions about these specifications contact Thomas Ferguson at 312-353-5783 or

tferguson@gpo.gov. Questions about these specifications should be forwarded at least 1 workday before the 

Quote Deadline, in order to be addressed prior to bid submission.

Email requests for new award information (available approximately 2 weeks after bid opening) to GPO 

Northcentral Front Desk at kdodson@gpo.gov. 
Single Leaf Forms and Multiple-Part Sets Page 3 of 18 

1503-S 

SECTION 1. – GENERAL TERMS AND CONDITIONS

GPO CONTRACT TERMS: Any contract which results from this Invitation for Bid will be subject to the 

applicable provisions, clauses, and supplemental specifications of GPO Contract Terms (GPO Pub. 310.2, 

effective December 1, 1987 (Rev. 1-18)) and GPO Contract Terms, Quality Assurance Through Attributes 

Program for Printing and Binding (GPO Pub. 310.1, effective May 1979 (revised 9-19)). 

• GPO Contract Terms (GPO Publication 310.2) – https://www.gpo.gov/docs/default-source/forms-andstandards-files-for-vendors/contract-terms-01-18.pdf. 

• GPO QATAP (GPO Publication 310.1) – https://www.gpo.gov/docs/default-source/forms-andstandards-files-for-vendors/qatap-rev-09-19.pdf. 

• More GPO Publications can be found at: https://www.gpo.gov/how-to-work-with-us/vendors/formsand-standards. 

QUALITY ASSURANCE LEVELS AND STANDARDS: The following levels and standards shall apply to 

these specifications:

Product Quality Levels: 

(a) Printing (page related) Attributes -- Level III. 

 (b) Finishing (item related) Attributes -- Level III. 

Inspection Levels (from ANSI/ASQC Z1.4): 

(a) Non-destructive Tests -- General Inspection Level I. 

 (b) Destructive Tests -- Special Inspection Level S-2. 

Specified Standards: The specified standards for the attributes requiring them shall be:

Attribute Specified Standard 

 P-7. Type Quality and Uniformity Government Furnished Material or

 Approved Proof 

 P-8. Halftone Match (Single and Double Impression) Government Furnished Material or

 Approved Proof 

 P-9. Solid and Screen Tint Color Match Pantone Matching System 

PREDOMINANT PRODUCTION FUNCTION: The predominant production function is printing. Bidders 

who must subcontract this operation will be declared non-responsible.

PREAWARD SURVEY: In order to determine the responsibility of the prime contractor or any subcontractor, 

the Government reserves the right to conduct an on-site preaward survey at the contractor's/subcontractor's facility 

or to require other evidence of technical, production, managerial, financial, and similar abilities to perform, prior 

to the award of a contract. As part of the financial determination, the contractor in line for award may be required 

to provide one or more of the following financial documents: 

1) Most recent profit and loss statement 

2) Most recent Balance Sheet 

3) Statement of cash flows 

4) Current official bank statement 

5) Current lines of credit (with amounts available) 

6) Letter of commitment from paper supplier(s) 

7) Letter of commitment from any subcontractor 

The documents will be reviewed to validate that adequate financial resources are available to perform the contract 

requirements. Documents submitted will be kept confidential and used only for the determination of responsibility 

by the Government. Failure to provide the requested information in the time specified by the Government may 
Single Leaf Forms and Multiple-Part Sets Page 4 of 18

1503-S

result in the Contracting Officer not having adequate information to reach an affirmative determination of 

responsibility.

POSTAWARD CONFERENCE: At the Government’s option, immediately after award a postaward conference 

with contractor representative(s) may be held via telephone conference to discuss the requirements of the contract.

OPTION TO EXTEND THE CONTRACT TERM: The Government has the option to extend the term of this 

contract for a period of 12 months by written notice to the contractor not later than 30 days before the contract 

expires. If the Government exercises this option, the extended contract shall be considered to include this clause, 

except, the total duration of the contract may not exceed 3 years as a result of, and including, any extension(s) 

added under this clause. Further extension may be negotiated under the “Extension of Contract Term” clause. See 

also “Economic Price Adjustment” for periodic pricing revision.

EXTENSION OF CONTRACT TERM: At the request of the Government, the term of any contract resulting 

from this solicitation may be extended for such period of time as may be mutually agreeable to the GPO and the 

contractor.

ECONOMIC PRICE ADJUSTMENT: The pricing under this contract shall be adjusted in accordance with this 

clause, provided that in no event will any pricing adjustment be made that would exceed the maximum permissible 

under any law in effect at the time of the adjustment. There will be no adjustment for orders placed during the 

first period specified below. Pricing will thereafter be eligible for adjustment during the second and any 

succeeding performance period(s). For each performance period after the first, a percentage figure will be 

calculated as described below and that figure will be the economic price adjustment for that entire next 

period. Pricing adjustments under this clause are not applicable to reimbursable postage or transportation costs, 

or to paper, if paper prices are subject to adjustment by separate clause elsewhere in this contract.

For the purpose of this clause, performance under this contract will be divided into successive periods. The first 

period will extend from February 1, 2024 and ending January 31, 2025, and the second and any succeeding 

period(s) will extend for 12 months from the end of the last preceding period, except that the length of the final 

period may vary. The first day of the second and any succeeding period(s) will be the effective date of the 

economic price adjustment for that period.

Pricing adjustments in accordance with this clause will be based on changes in the seasonally adjusted “Consumer 

Price Index For All Urban Consumers - Commodities Less Food” (Index) published monthly in the CPI Detailed 

Report by the U.S. Department of Labor, Bureau of Labor Statistics.

The economic price adjustment will be the percentage difference between Index averages as specified in this 

paragraph. An index called the variable index will be calculated by averaging the monthly Indexes from the 12-

month interval ending 3 months prior to the beginning of the period being considered for adjustment. This average 

is then compared to the average of the monthly Indexes for the 12-month interval ending October 31, 2024 called 

the base index. The percentage change (plus or minus) of the variable index from the base index will be the 

economic price adjustment for the period being considered for adjustment.

The Government will notify the contractor by contract modification specifying the percentage increase or decrease 

to be applied to invoices for orders placed during the period indicated. The contractor shall apply the percentage 

increase or decrease against the total price of the invoice less reimbursable postage or transportation costs and 

separately adjusted paper prices. Payment discounts shall be applied after the invoice price is adjusted.

If the Government exercises an option, the extended contract shall be considered to include this economic price 

adjustment clause.
Single Leaf Forms and Multiple-Part Sets Page 5 of 18 

1503-S 

ASSIGNMENT OF JACKETS, PURCHASE AND PRINT ORDERS: A GPO jacket number will be assigned 

and a purchase order issued to the contractor to cover work performed. The purchase order will be supplemented 

by individual "Print Orders" for each job placed with the contractor. The print order, when issued, will indicate 

the quantity to be produced and other information pertinent to the particular order. 

PREAWARD SURVEY: In order to determine the responsibility of the prime contractor or any subcontractor, 

the Government reserves the right to conduct an on-site preaward survey at the contractor's/subcontractor's 

facility or to require other evidence of technical, production, managerial, financial, and similar abilities to 

perform, prior to the award of a contract. 

ORDERING: Items to be furnished under the contract shall be ordered by the issuance of print orders by the 

Government. Orders may be issued under the contract from February 1, 2024 and ending January 31, 2025 

plus for such additional period(s) as the contract is extended. All print orders issued hereunder are subject to the 

terms and conditions of the contract. The contract shall control in the event of conflict with any print order. A 

print order shall be "issued" for purposes of the contract, when it is either deposited in the U.S. Postal Service 

mail or otherwise furnished to the contractor in conformance with the schedule. 

REQUIREMENTS: This is a requirements contract for the items and for the period specified herein. 

Shipment/delivery of items or performance of work shall be made only as authorized by orders issued 

in accordance with the clause entitled “Ordering”. 

The quantities of items specified herein are estimates only, and are not purchased hereby. Except as may be 

otherwise provided in this contract; if the Government’s requirements for the items set forth herein do not result 

in orders in the amounts or quantities described as “estimated”, it shall not constitute the basis for an equitable 

price adjustment under this contract. The Government shall not be required to purchase from the contractor, 

requirements in excess of the limit on total orders under this contract, if any. 

Orders issued during the effective period of this contract and not completed within that time are to be completed 

by the contractor within the time specified in the order. The rights and obligations of the contractor and the 

Government respecting those orders shall be governed by the terms of this contract to the same extent as if 

completed during the effective period of this contract.

When production covered by this contract is required before the dates specified under this contract, and the 

contractor will not accept the accelerated schedule, the Government may procure this requirement from another 

source for that accelerated schedule.

The Government may issue orders which provide for shipment/delivery to, or performance at, multiple 

destinations. 

Subject to any limitations elsewhere in this contract, the contractor shall furnish to the Government all items set 

forth herein which are called for by print orders issued in accordance with the “Ordering” clause of this contract. 

OPTIONS: Whenever an option is indicated in the specifications, it is the Government's option, not the 

contractor’s, unless it is specifically stated otherwise.

PAYMENT: Submit invoices for payment via the GPO fax gateway (if no samples are required) utilizing the 

GPO barcode coversheet program application is the most efficient method of invoicing. Instruction for using this 

method can be found at the following web address: 

http://winapps.access.gpo.gov/fms/vouchers/barcode/instructions.html

Invoices may also be mailed to: U.S. Government Publishing Office, Office of Financial Management, Attn: 

Comptroller, Stop: FMCE, Washington, DC 20401. 
Single Leaf Forms and Multiple-Part Sets Page 6 of 18 

1503-S 

For more information about the billing process refer to the General Information of the Office of Finance web page 

located at https://www.gpo.gov/how-to-work-with-us/vendors/how-to-get-paid. 

CONTRACTOR’S INVOICE FOR PAYMENT MUST BE ITEMIZED IN ACCORDANCE WITH THE 

SCHEDULE OF PRICES AND ISSUED TO GPO WITHIN 10 WORKDAYS AFTER COMPLETION OF 

EACH INDIVIDUAL PRINT ORDER. FAILURE TO ITEMIZE IN ACCORDANCE WITH THE 

SCHEDULE OF PRICES OR ISSUED TO GPO WITHIN 10 WORKDAYS AFTER ORDER 

COMPLETION MAY RESULT IN DELAYED PAYMENT.

In addition, contractor is required to email delivery receipts and final invoice in PDF format to originator of each 

GPO Form 2511 print order. All documents should be in one PDF file. Originator’s email address will be found 

at the bottom of each GPO Form 2511 print order. Subject line of the email will be the print order number. 

RECEIPTS FOR DELIVERY: Contractor must furnish their own receipts for delivery. These receipts must 

include the GPO jacket, program, and print order numbers, total quantity shipped and/or delivered, number of 

cartons and quantity per carton; date delivery made; and signature of the Government agent accepting delivery. 

Original copy of these receipts or other acceptable proof must accompany the contractor’s voucher for payment.
Single Leaf Forms and Multiple-Part Sets Page 7 of 18

1503-S

SECTION 2. – SPECIFICATIONS

SCOPE: These specifications cover the production of miscellaneous single leaf forms, multipart NCR sets, and 

labels that require such operations as electronic prepress, reproducibles, proofs, printing, numbering, padding,

packing, and distribution.

TITLE: Single Leaf Forms and Multipart-Part Sets.

Specifications apply equally to both single leaf forms and multipart sets unless otherwise noted.

TRIM SIZES: Various trim sizes will be ordered and paid for in their respective “Format” classification as 

follows:

Format A: Up to and including 5-1/2 x 8-1/2”.

Format B: Over 5-1/2 x 8-1/2” up to and including 8-1/2 x 11”.

An occasional order may require a finished trim size over 8-1/2 x 11” up to and including 17 x 11”.

NUMBER OF ORDERS/TRIM SIZE/QUANTITY - Single Leaf Forms:

Format A: Approximately 5 orders per year at 500 up to 10,000 or more copies per order. 

Format B: Approximately 10 orders per year at 500 up to 25,000 copies per order. Single Leaf Forms for 

two color printing approximately 1,000 to 25,000 copies per order.

An occasional order may exceed 25,000 copies up to 100,000. 

NOTE: A single leaf form order over 8-1/2 x 11” may be ordered, up to and including 17 x 11”, reimbursement 

will be made in accordance with the GPO “Section 4. Schedule of Prices”.

NUMBER OF ORDERS/DETACH TRIM SIZES/QUANTITY – Multipart Sets:

Approximately 10 orders per year for trim sizes up to 8-1/2 x 11”.

2-part to 6-part sets. Approximately 500 to 25,000 or more sets per order. An occasional order for multipart sets 

may exceed 25,000 sets up to 100,000 sets.

No Quantity Variation Allowed.

GOVERNMENT TO FURNISH: PDF file created on Macintosh (OS X or higher) or Windows (8 or higher) 

furnished on CD/DVD, USB flash drive or via e-mail. Note, an occasional order may provide the digital image 

in JPEG.

Fonts: All screen and printer fonts will be furnished or embedded in files. The contractor is cautioned that 

furnished fonts are the property of the Government and/or its originator. All furnished fonts are to be eliminated 

from the contractor’s archive immediately after completion of the contract.

Electronic Prepress: Immediately upon receipt and prior to image processing, the contractor shall perform a 

basic check (preflight) of the furnished media and publishing files to assure correct output of the required 

reproduction image. Any errors, media damage, or data corruption that might interfere with proper file image 

processing must be reported to Columbus GPO Contracting Office prior to further performance.

The contractor shall create or alter any necessary trapping, set proper screen angles and screen frequency, and 

define file output selection for the imaging device being utilized. Furnished files must be imaged as necessary 

to meet the assigned quality level.

Upon completion of the order, the contractor must furnish final production native application files (digital 
Single Leaf Forms and Multiple-Part Sets Page 8 of 18 

1503-S 

deliverables) when any changes or typesetting is required on furnished material. The digital deliverables must 

be an exact representation of the final printed product and shall be returned on the same type of storage media 

(CD/DVD. USB flash drive, or emailed) as was originally furnished.

Delivery/Shipping Status Report Form.

GPO Form 2511, Print Order. 

Identification markings such as register marks, ring folios, rubber stamped jacket numbers, commercial 

identification marks of any kind, etc., except GPO imprint, form number, and revision date, carried on copy, 

must not print on finished product. 

CONTRACTOR TO FURNISH: All materials and operations, other than those listed under “Government to 

Furnish,” necessary to produce the product(s) in accordance with these specifications.

TYPESETTING: An order may require the contractor to set lines of type (same or similar) normally up to 40 

lines of type for changes and/or revisions but could be up to 100 lines of type. Typeset as indicated on the 

individual Print Order or digital image (usually PDF or JPEG). 

REPRODUCIBLES: The contractor must make all reproducibles required. The contractor is responsible for 

determining what type reproducibles will be used but must maintain the quality level specified in the contract. 

No separate charges will be allowed for the various types of reproducibles that may be used.

Further, the contractor is responsible for outputting all images contained on furnished material, regardless of the 

production process, at the highest effective resolution possible. The contractor is responsible for determining 

the appropriate output resolution to achieve optimal results for such design elements as blends, gradients, 

halftones, type and other images. This determination should be made using factors such as stock, imaging 

device (or press) being used, and other factors unique to the contractors production environment. 

PROOFS: The Print Order will indicate whether a “Press Quality” PDF soft proof is required. 

No Proofs required on the Print Order: Contractor will still be responsible for final output that is in 

conformance with the PDF/JPEG (visuals/copy) as provided. The contractor will be responsible for reporting 

immediately to the GPO if there is any discrepancy within the content of the digital file versus the output for 

print.

Proofs are required on the Print Order: Contractor to submit one “Press Quality” PDF soft proof (for 

content only) using the same Raster Image Processor (RIP) that will be used to produce the final printed 

product. PDF proof will be evaluated for text flow, image position, and color breaks. Proof will not be used for 

color match. Email proofs on or before the date and individual(s) indicated on the Print Order. 

If any contractor’s errors are serious enough in the opinion of the GPO to require revised proofs, the revised 

proofs are to be provided at no expense to the Government. No extra time can be allowed for this reproofing; 

such operations must be accomplished within the original production schedule allotted in the specifications.

The contractor is cautioned that these proofs must be made from the final digital files (used for this printing) that 

are to be delivered to the Government. 

Author’s Alterations and Revised Proofs: Authors Alterations (refer to page 17 (item 16) of GPO Contract 

Terms 310.2) and revised proofs may be required. These author’s alterations and revised proofs will only be 

paid for when errors are caused by the Government and the Government deems it necessary to require additional 

author’s alterations and revised proofs.

The contractor must not print prior to receipt of “OK to Print” by phone, fax, or e-mail.
Single Leaf Forms and Multiple-Part Sets Page 9 of 18

1503-S

STOCK/PAPER: The specifications of all paper furnished must be in accordance with those listed herein or 

listed for the corresponding JCP Code numbers in the “Government Paper Specification Standards No. 13” 

dated February 2020. All paper used in each copy must be of a uniform shade.

Color of stock/paper furnished shall be of a uniform shade and a close match by visual inspection of the JCP 

and/or furnished color sample(s). The Contracting Officer reserves the right to reject shipments of any order 

printed on stock/paper the color of which, in his opinion, materially differs from that of the color sample(s).

The stock/paper to be used will be indicated on each Print Order.

Single Leaf Forms:

White or Color Writing (With Tablet Stock Option), basis weight: 20-24 lbs. per 500 sheets, 17 x 22”, equal 

to JCP Code D10.

White Uncoated Text, basis weight: 50-60 lbs. per 500 sheets, 25 x 38”, equal to JCP Code A60.

White No. 1 Smooth-Finish Text, basis weight: 60-70 lbs. per 500 sheets, 25 x 38”, equal to JCP Code A61.

 Smooth and Fancy-finish Cover, White and Colored to include neon bright, basis size 20 x 26", 60 or 65 lbs. 

 per 500 sheets, equal to JCP Code L-21. 

White or Color Index, basis weight: 110 lbs. per 500 sheets, 25-1/2 x 30-1/2”, equal to JCP Code K10.

 White Pressure Sensitive Uncoated Label stock, basis weight 50 - 60 lbs. (500 sheets, 25 x 38”), permanent 

 adhesive, suitable split liner (minimum 1 split per finished label), uncoated.

Multipart sets: Blue or black image chemical transfer. Majority of the orders will require blue image transfer 

and is the default when not indicated on the Print Order.

White and Colored Carbonless Bond (CB, CFB, and CF), basis weight: 13 to 17 lbs. (as indicated on 

individual Print Order), basis sheet 17 x 22”, equal to JCP O-80.

White and Manila High-Finish Tag, basis weight: (7-1/2 point) 200 lbs. per 500 sheets, 24 x 36”, similar to 

JCP Code P10 except for weight and color.

PRINTING: At contractor’s option, the product may be produced via conventional offset or digital printing 

provided that Quality Level 3 standards are maintained. Final output must be a minimum of 150 line screen and 

at a minimum resolution of 2400 x 2400 dpi x 1 bit or 600 x 600 dpi x 8 bit depth technology. Digital device must 

have a RIP that provides an option for high quality color matching such as Device Links Technology and/or ICC 

Profiles.

Single Leaf Forms: Print face only, or face and back in one or two colors of ink as indicated on the individual 

Print Order. Anticipate majority of orders will print in black ink. On two color orders anticipate some ink 

trapping. 

Most orders consist of type and rule matter; an occasional order will require reverse type, flat tones and 

halftones. When colored inks are required, they will be designated by Pantone numbers.

Multipart sets: Print face only, or face and back in one or two color(s) of ink for the body as indicated on the 

individual Print Order. Anticipate majority of orders that the body ink color will print in black. 

Changes on Multipart Sets will be indicated on individual Print Order as Marginal (including copy 

designations), Minor, and Major changes. These changes are defined in GPO Contract Terms (GPO Pub. 

310.2), Supplemental Specifications 12 on page 16. Copy designations may be in the body ink color or red ink 

as indicated on individual Print Order. 

Note, if marginal copy designations ink color is red, this is not billable as an additional ink color.

Numbering: When ordered, number in red or black ink, (3/16” to 1/4” high or as otherwise specified), as 

indicated on the Print Order, usually one series. Only one setup and running charge will be allowed for each 

separate number series. Each number series may appear in one to three locations. Numbering ink may be 

different than body form ink, no additional ink charge allowed. No missing numbers.

Crash numbering on multipart sets is acceptable.
Single Leaf Forms and Multiple-Part Sets Page 10 of 18

1503-S

MARGINS: Margins will be as indicated on the Print Order or furnished copy.

Single Leaf Forms: Some orders bleed up to 4 sides. Contractor may be required to create bleeds. 

Reduce/enlarge copy to fit specified margins.

Multipart Sets: Adequate gripper for body of form.

BINDING: 

Folding: Single Leaf Forms fold as described on the individual Print Order with one or two parallel folds

(accordion, letter-fold or wrap-around).

Perforating and Scoring: An occasional order will require perforating and scoring as described on the 

individual Print Order.

Drilling: Drill one to three holes 1/4”, 5/16”, or 3/8” in diameter; 3/8” from edge to center of holes, as indicated 

on the Print Order. Center to center spacing as ordered. Specific drilling instructions will be indicated on the 

individual Print Order.

Padding: Pad as indicated on the on the individual Print Order. Gum and crush or any suitable padding 

compound may be used. Backboards must be .020” chipboard, newsboard or equal. Anticipate orders will 

usually pad at the top with 50 or 100 leaves per pad.

Multipart Set Construction: Edge glue (fan-apart or equal) on either the short or long dimension, with bound 

edge to never exceed 11”. Adhesive must provide sufficient strength to guarantee parts will remain together under 

normal handling and storage.

PACKING: Pack as indicated on individual Print Order.

Shrink-film wrap in quantities as indicated on the individual Print Order (usually 25, 50, 100, 250, or 500 per 

package).

Individual orders may require cushioned shipping bags, preparing shipping bundles, packing and sealing 

shipping containers, marking packages and shipping bundles or containers by printing, stenciling, or labeling.

The method of packing will be indicated on the Print Order for each individual job and must be accomplished in 

accordance with specifications. Each package unit must contain uniform quantities. Shipping containers and 

bundles furnished by the contractor shall not exceed 45 pounds unless otherwise indicated on the individual 

Print Order.

LABELING AND MARKING: Contractor to download the “Labeling and Marking Specifications” form 

(GPO Form 905, R. 7-15) from gpo.gov, fill in appropriate blanks, and attach to shipping containers.

INSPECTION SAMPLES: When indicated on the Print Order, or otherwise requested, two samples shall be 

sent for inspection to the U.S. Government Publishing Office address as specified. 

These samples cannot be deducted from the total quantity ordered. The package or envelope containing the 

samples shall be identified by the GPO Jacket number, Program number, Print Order number, title, and include a 

facsimile of the Print Order on which they were ordered. The contractor will comply with the shipping schedule 

regardless of this requirement and will be notified of the test results only if there are deficiencies.

DEPARTMENTAL RANDOM COPIES (BLUE LABEL) for Single Leaf Forms only: Orders of 10,000 

copies or more must be divided into 125 equal sublots. A random copy must be selected from each sublot. A 

random copy must be selected from each sublot. Do not choose copies from the same general area in each 

sublot. The contractor will be required to certify that copies were selected as directed using GPO Form 917-
Single Leaf Forms and Multiple-Part Sets Page 11 of 18 

1503-S 

Certificate of Selection of Random Copies (located on GPO.gov). The random copies constitute a part of the 

total quantity ordered, and no additional charge will be allowed. 

These randomly selected copies must be packed separately and identified by a special label (GPO Form 2678-

Departmental Random Copies (Blue Label) that must be printed on blue paper and affixed to each affected 

container. This form can be downloaded from GPO.gov. The container and its contents shall be recorded 

separately on all shipping documents and sent in accordance with the distribution list or indicated on the Print 

Order.

A copy of the Print Order and a signed Certificate of Selection of Random Copies, must be included inside the 

container on the top. 

DISTRIBUTION: Deliver f.o.b. destination using common courier via traceable means or as otherwise 

directed on the individual Print Order. Contractor shipping cost must be included in the GPO Schedule of 

Prices – Item IV. 

Orders usually deliver to one location but up to 3 locations may be required per Print Order. Orders will deliver

to addresses all within the following states: Wisconsin, Illinois, Michigan, Indiana, North Dakota, South Dakota, 

Nebraska, Minnesota, Iowa, and Missouri. An occasional order may require a delivery to a state that is not 

listed.

Ship/Delivery date indicated on Print Order is the date the shipment MUST BE RECEIVED at destination.

SCHEDULE: Contractor must not start production of any job prior to receipt of the individual Print Order 

(GPO Form 2511) and furnished material. 

Most orders will be e-mailed to the contractor. Contractor must confirm receipt of e-mail within 30 minutes of 

receipt.

An occasional order will require the contractor to pick up Print Order and furnished material from a designated 

address. 

The following schedule begins the workday after notification of the availability of print order and furnished 

material; the workday after notification will be the first workday of the schedule. 

When proofs are ordered, a minimum of 7 workdays will be required for production and delivery which includes 

the Government proof hold time of 2 workdays. 

The following schedule is anticipated:

Quantity Range of

Order Workdays 

Up to 5,000 5 to 10 

5,001 to 25,000 11 to 13 

25,001 and over 14 to 16

RECEIPT FOR DELIVERY: Contractor must furnish their own receipts for delivery. These receipts must 

include the GPO Jacket, Program and Print Order numbers, total quantity delivered; number of cartons and 

quantity per carton; and date delivery made, and signature of the Government agent accepting delivery. The 

original copy of this receipt must accompany the contractor’s voucher for payment. 

Unscheduled material such as shipping documents, receipts or instructions, delivery lists, labels, etc., will be 

furnished with each order or shortly thereafter. In the event such information is not received in due time, the 

contractor will not be relieved of any responsibility in meeting the shipping schedule because of failure to 

request such information.
Single Leaf Forms and Multiple-Part Sets Page 12 of 18

1503-S

RETURN OF GOVERNMENT FURNISHED PROPERTY: The contractor must return all material 

furnished by the Government along with any films made by the contractor, together with one printed sample of 

each job, to the address listed on the Print Order.

These materials must be packaged, properly labeled and returned separate from the entire job via traceable 

means. The contractor must be able to produce a separate signed receipt for these materials at any time during 

the contract.

All expenses incidental to pickup/return of materials, and furnishing sample copies and proofs, must be borne by 

the contractor.
Single Leaf Forms and Multiple-Part Sets Page 13 of 18

1503-S

SECTION 3. – DETERMINATION OF AWARD

The Government will determine the lowest bid by applying the prices offered in the “Schedule of Prices” to the 

following units of production which are the estimated requirements to produce one year’s orders under this 

contract. These units do not constitute, nor are they to be construed as, a guarantee of the volume of work which 

may be ordered for a like period of time.

The following item designations correspond to those listed in the “Schedule of Prices”.

I. (1) (2)

A.1. (a) 5 3

(b) 50 30

2. (a) 1 5

(b) 10 50

3. (a) 1 1

(b) 5 5

B.1. (a) 2 III.

(b) 20 (a) 90

2. (a) 4 (b) 18

(b) 230 (c) (1) 12

3. (a) 2 (2) 20

(b) 130 (3) 420

4. (a) 1 (d)(1) 1

(b) 10 (2) 10

5. (a) 1 (e) 20

(b) 10 (f) (1) 10

6. (a) 1 (2) 1

(b) 10 (3) 1

7. (a) 1 (g) 50

(b) 10 (h) 200

 (i) 5

II. A. (1) (2)

(a) 10 5 IV.

(b) 10 5 (a) 25

(c) 5 10

(d) 5 20

(e) 15 30

(f) 10 10

(g) 10 5

 B.

(a) 400

(b) 400

(c) 160

(d) 10

(e) 10
Single Leaf Forms and Multiple-Part Sets Page 14 of 18 

1503-S 

SECTION 4. – SCHEDULE OF PRICES

Quotes offered are f.o.b. destination to one or more of the following states: Wisconsin, Illinois, Michigan, 

Indiana, North Dakota, South Dakota, Nebraska, Minnesota, Iowa, and Missouri.

Prices must be submitted for the entire term of the contract and bids qualified for a lesser period will not be 

considered. 

Prices must include the cost of all required materials and operations for each item listed in accordance with these 

specifications. 

Bidder must make an entry in each of the spaces provided. Bids submitted with any obliteration, revision, or 

alteration of the order and manner of submitting bids, may be declared nonresponsive. 

An entry of NC (No Charge) shall be entered if bidder intends to furnish individual items at no charge to the 

Government. 

Quotes submitted with NB (No Bid), NA (Not Applicable), or blank spaces for an item may be declared 

nonresponsive. 

The Contracting Officer reserves the right to reject any offer that contains prices for individual items of 

production (whether or not such items are included in the Determination of Award) that are inconsistent or 

unrealistic in regard to other prices in the same offer or to GPO prices for the same operation if such action 

would be in the best interest of the Government. 

All vouchers submitted to the GPO shall be based on the most economical method of production. 

Fractional parts of 100 will be prorated at the per 100 rate.

I. PRINTING AND TRIMMING TO SIZE: Prices offered shall include the cost of all required materials 

and operations necessary for the complete production and delivery of the products listed in accordance with 

these specifications except for Items. II. Stock/Paper and III. Additional Operations. 

Quotes for each “Format” shall be for any trim size up to the maximum trim size listed for each of the 

“Formats” as outlined in Section 2. – Specifications. 

Format A: Up to and including 5-1/2 x 8-1/2”. 

Format B: Over 5-1/2 x 8-1/2” up to and including 8-1/2 x 11”. 

NOTE: If any Single Leaf Form order requires a FINISHED trim size over 8-1/2 x 11” up to and including 17 

x 11”, reimbursement will be made at double the rate offered for Format B under Items I. A. and B. 1. (a) and 

(b), 2. (a) and (b), and 3. (a) and (b) below. 

Format A Format B

A. Single Leaf Form: (1) (2)

 1. Printed one side only in a single ink color:

 (a) Makeready and setup charge ................................................... $__________ $__________ 

 (b) Running per 100 copies ........................................................... $__________ $__________ 

 2. Printed two sides in a single ink color: 

 (a) Makeready and setup charge ................................................... $__________ $__________ 

 (b) Running per 100 copies ........................................................... $__________ $__________ 

 3. Printing an additional ink color, per side: 

 (a) Makeready and setup charge ................................................... $__________ $__________ 

 (b) Running per 100 copies ........................................................... $__________ $__________ 

(COMPLETE AND SUBMIT THIS PAGE WITH YOUR QUOTE) ________ (Initials)
Single Leaf Forms and Multiple-Part Sets Page 15 of 18

1503-S

B. Multipart sets for Format A and B line item pricing 1 through 5, print one ink color on face only. 

Note: The edge binding are included in the part set costs as well as the collating charge per respective number 

of part sets as follows:

Quotes shall be for any trim size Up to the 8-1/2 x 11”. 

1. 2-part set:

(a) Makeready & set up charge .....................................................$__________

(b) Running per 100 sets...............................................................$__________

2. 3-part set:

(a) Makeready & set up charge .....................................................$__________

(b) Running per 100 sets...............................................................$__________

3. 4-part set:

(a) Makeready & set up charge .....................................................$__________

(b) Running per 100 sets...............................................................$__________

4. 5-part set:

(a) Makeready & set up charge .....................................................$__________

(b) Running per 100 sets...............................................................$__________

5. 6-part set:

(a) Makeready & set up charge .....................................................$__________

(b) Running per 100 sets...............................................................$__________

6. Printing one color on the back (same image for each part):

(a) Makeready & set up charge per set..........................................$__________

(b) Running per 100 sides of leaves..............................................$__________

7. Printing an additional ink color (each color):

(a) Makeready & set up charge per set..........................................$__________

(b) Running per 100 sides of leaves..............................................$__________

(COMPLETE AND SUBMIT THIS PAGE WITH YOUR QUOTE)

___________

(Initials)
Single Leaf Forms and Multiple-Part Sets Page 16 of 18 

1503-S 

II. STOCK/PAPER: Payment for all stock/paper supplied by the contractor under the terms of these 

specifications, as ordered on the individual Print Orders, will be based on the net number of leaves furnished for 

the product(s) ordered in the applicable “Format” group. The cost of any stock/paper required for makeready or 

running spoilage must be included in the prices offered. 

Format A: Up to and including 5-1/2 x 8-1/2”. 

Format B: Over 5-1/2 x 8-1/2” up to and including 8-1/2 x 11”. 

 Per 100 Leaves 

Format A Format B

A. Single Leaf Forms: (1) (2) 

(a) White Writing (16 lbs.) ............................................................... $__________ $__________ 

(b) Colored Writing (16 lbs.) ............................................................ $__________ $__________ 

(c) White Uncoated Text (60 lbs.) ................................................... $__________ $__________ 

(d) White No. 1 Smooth-Finish Text, (70 lbs.) ................................ $__________ $__________ 

(e) White Index (110 lbs.) ................................................................ $__________ $__________ 

(f) Colored Index (110 lbs.) ............................................................. $__________ $__________ 

(g) White Pressure Sensitive Uncoated Label stock, (50 - 60 lbs.)...$___________ $___________

 Per 100 Leaves 

B. Multi-part Sets (Over 5-1/2 x 8-1/2” to 8-1/2 x 11”) 

 (a) White Chemical Transfer Bond, 

CF or CB (13-17 lbs.)..........................................................$_______________ 

 (b) Colored Chemical Transfer Bond, 

CF or CB (13-17 lbs.) ................................................................. .........$_______________ 

 (c) White Chemical Transfer Bond, 

 CFB (13-17 lbs.) ......................................................................... .........$ ________ 

 (d) Colored Chemical Transfer Bond,

 CFB (13-17 lbs.) ......................................................................... .........$ ________ 

 (e) White and Manila High-Finish Tag, 

 CF, 7-1/2 point (200 lbs.) .......................................................... .........$ _________ 

(COMPLETE AND SUBMIT THIS PAGE WITH YOUR QUOTE)

___________ 

(Initials)
Single Leaf Forms and Multiple-Part Sets Page 17 of 18 

1503-S 

III. ADDITIONAL OPERATIONS: The prices offered for each of the following items must include the cost 

of all required materials and operations necessary, in accordance with these specifications.

(a) Typesetting ................................................................ per each set of 20 lines of type .. $ ___________ 

Note: factional number of lines of type will round up to the next multiple of 20 lines of 

type. Example, if 30 lines of type are required then the contractor is allowed to invoice 

for 40 lines of type. 

 (b) PDF Proofs ................................................................. per order .................................... $ ___________ 

(c) Numbering per Single Leaf Form and per Multipart Set: 

(1) Makeready and/or Setup ...................................... per series .................................... $ ___________ 

(2) Running per 100 leaves for Single Leaf Forms .. per series .................................... $ ___________ 

 (3) Running per 100 sets of Multipart Sets ............... per series .................................... $ ___________ 

(d) Perforating/Scoring, up to 3 lines: 

 (1) Makeready and/or Setup .......................................................................................... $ ___________ 

 (2) Running per 100 Copies .......................................................................................... $ ___________ 

(e) Drilling up to 3 holes per run ..................................... per 100 leaves ............................ $ ___________ 

(f) Changes: 

 (1) Marginal Changes ............................................... per change ................................. $ 

(2) Minor Changes .................................................... per change ................................. $ 

(3) Major Changes ..................................................... per change ................................. $ 

(g) Padding (assembling leaves into pads, stacking,

 gum or gum/crash, and slicing pads apart), 

 includes backboards ................................................... per pad ....................................... $ ___________ 

 

 (h) Shrink-film packaging ................................................ each package ............................. $ ___________ 

 (i) Authors alternations ................................................... desktop time per hour ................ $ ___________ 

IV: DELIVERY CHARGES: 

Bidders are to offer a price for delivery to the various Federal Printing Regions (see page 10). Pallets may be 

required for deliveries in excess of 20 cartons or 800 lbs.* per GPO contract terms. The prices offered, as 

applicable, will be applied to the weight of the ordered quantity. Inside deliveries may be required. No 

adjustments will be made if the contractor ships from more than one location.

 Cost Per Carton Weight 

(a) Flat rate for one carton Up to 40 lbs. .............. $ ____________ 

 

NOTE: Failure to offer a delivery charge may eliminate a bidder from consideration for award. 

 

(COMPLETE AND SUBMIT THIS PAGE WITH YOUR QUOTE)

___________ 

(Initials)
Single Leaf Forms and Multiple-Part Sets Page 18 of 18

1503-S

SECTION 4. – SCHEDULE OF PRICES

SHIPMENT(S): Shipments will be made from: City __________________________, State _______________

If shipment is not made from evaluation point, the contractor will be responsible for any additional shipping 

costs incurred.

DISCOUNTS: Discounts are offered for payment as follows: __________ Percent, __________ calendar days. 

See Article 12 “Discounts” of Solicitations Provisions in GPO Contract Terms (Publication 310.2).

AMENDMENT(S): Bidder hereby acknowledges amendment(s) number(ed) ___________________________

BID ACCEPTANCE PERIOD: In compliance with the above, the undersigned agree, if this bid is accepted 

within _____________ calendar days (60 calendar days unless a different period is inserted by the bidder) from 

the date for receipt of bids, to furnish the specified items at the price set opposite each item, delivered at the 

designated point(s), in exact accordance with specifications.

NOTE: Failure to provide a 60-day bid acceptance period may result in expiration of the bid prior to award.

BIDDER’S NAME AND SIGNATURE: Unless specific written exception is taken, the bidder, by signing and 

submitting a bid, agrees with and accepts responsibility for all certifications and representations as required by 

the solicitation and GPO Contract Terms – Publication 310.2. When responding by email, fill out and return 

one copy of all pages in “SECTION 4. – SCHEDULE OF PRICES,” including initialing/signing where 

indicated. Valid electronic signatures will be accepted in accordance with the Uniform Electronic Transactions 

Act, §2. Electronic signatures must be verifiable of the person authorized by the company to sign bids.

Failure to sign the signature block below may result in the bid being declared non-responsive.

Bidder __________________________________________________________________________________

(Contractor’s Name) (GPO Contractor’s Code)

_______________________________________________________________________________________

(Street Address)

_______________________________________________________________________________________

(City – State – Zip Code)

By______________________________________________________________________________________

(Printed Name, Signature, and Title of Person Authorized to Sign this Bid) (Date)

_______________________________________________________________________________________

(Person to be Contacted) (Telephone Number) (Email)

THIS SECTION FOR GPO USE ONLY

Contracting Officer: ___________ Date ___________ Certifier by: __________ Date __________

(Initials) (Initials)