Jacket: 522-026

TITLE: FY’21 SY’21 3HSS 0421 MAILING FY’21 SY’21 4HSS 0621 MAILING

Agency: DLA Norfolk 5041-NB

BID OPENING: March 22, 2021 at 11am

Contractor Name Bid Terms Discount

Monarch Litho 040-60078 $90,909 

 

 

 

LU / RG

2% 20 days $89,090.82

Consol Graph INC. 190-23089 $97,492 0.50% 21 days $97,004.54

Advantage Mailing LLC 040-02494 $110,065.20 1% 20 days $108,964.55

HBP, INC 190-39820 $106,465 0.50% 20 days $105,932.68
Specifications by LU Jacket 522-026: DLA Norfolk / DLADS: 1-019071G 

Reviewed by RG . 

Page 1 of 9 

FACSIMILE BID SPECIFICATIONS 

U.S. Government Publishing Office (GPO) 

291 Virginia Beach Blvd., Ste. 401 

Virginia Beach Regional Printing Procurement Office 

Virginia Beach, Virginia 23462 

BID OPENING: Bids shall be opened at 11:00 a.m., prevailing Eastern Standard Time March 22, 2021 at the 

U.S. Government Publishing Office, Virginia Beach Regional Office, 291 Independence Blvd., Suite 401, 

Virginia Beach, VA 23462. Due to COVID-19, this will NOT be a public bid opening. 

ANY QUESTIONS BEFORE AWARD CONCERNING THESE SPECIFICATIONS CALL Ledo Ulerio (757) 

490-7943 AFTER AWARD, REFER ALL QUESTIONS TO YOUR CONTRACT ADMINISTRATOR WHOSE 

NAME APPEARS IN THE UPPER PORTION OF THE PURCHASE ORDER. NO COLLECT CALLS. 

BID SUBMISSION: Due to the COVID-19 pandemic, the physical office of Virginia Beach Regional Office will 

NOT be open. Based on this, bidders MUST submit email bids to bidsvirginiabeach@gpo.gov for this solicitation. 

No other method of bid submission will be accepted at this time. The jacket number and bid opening date must be 

specified in the subject line of the emailed bid submission. Bids received after 11:00 a.m. on the bid opening date 

specified above will not be considered for award. 

ADDITIONAL EMAILED BID 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 75 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. 

OFFERS: Offers must include the cost of all materials and operations for the total quantity ordered in accordance 

with these specifications. In addition, a price must be submitted for each additional 1,000’s. The price for 

additional quantities must be based on a continuing run, exclusive of all basic or preliminary charges and will not 

be a factor for determination of award. 

Note: The GPO 910 “BID” Form is no longer required; bidders are to fill out, sign/initial, as applicable, and return 

page 9. 

The jacket number and bid opening date must be specified with the emailed bid submission. Refer to Facsimile 

Bids in Solicitation Provisions of GPO Contract Terms, GPO Publication 310.2, as revised January, 2018. 

Bids received after 11:00 a.m. on the bid opening date specified above will not be considered for award. For 

information regarding the solicitation requirements prior to award, email Ledo Ulerio at lulerio@gpo.gov For 

contract administration after award, contact Ledo Ulerio at (757) 490-7943. 
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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 Publication 310.2, 

effective December 1, 1987 (Rev. 01-18)) and GPO Contract Terms, Quality Assurance Through Attributes 

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

GPO Contract Terms (GPO Publication 310.2) – 

https://www.gpo.gov/docs/default-source/forms-and-standards-files-for-vendors/contractterms2018.pdf 

GPO QATAP (GPO Publication 310.1) – 

https://www.gpo.gov/docs/default-source/forms-and-standards-files-for-vendors/qatap-rev-09-19.pdf 

DOING BUSINESS WITH GPO CUSTOMER SERVICES DURING CORONAVIRUS PANDEMIC 

Contractors should continue performance on contracts. Contractors must continue to fully comply with the terms 

and conditions of these contracts. Deliveries, proof approvals, and press sheet inspections for agencies may be 

impacted. It is requested that contractors contact a Government employee at the delivery location to confirm their 

availability to receive prior to shipping. 

Schedules and other adjustments will be made in accordance with GPO Contract Terms. Caution should be used 

to safeguard all products should any delivery delays be imposed by the Government. 

As a reminder, contractors must furnish contract compliance information required in accordance with GPO 

Contract Terms, Contract Clause 12: Notice of Compliance with Schedules. 

Contractors should immediately contact your GPO contract administrator(s) and/or contracting officer(s) to 

identify impacted orders if any delay is anticipated, including temporarily closure of a production facility or the 

planned suspension of any services. 

If you have any questions on a particular contract, please contact the Customer Services contract administrator 

and/or contracting officer for your contract (best method of communicating with them is via email). Office team 

e-mail addresses can be found at 

https://www.gpo.gov/how-to-work-with-us/agency/services-for-agencies/procurement-services-team 

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 pre-award 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 result in the Contracting Officer not having adequate information to reach an affirmative 

determination of responsibility. 

NOTE: Prior to award the apparent low vendor must be able to show ability to produce the product in question 

and may be asked to supply samples of similar items. 
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PAYMENT: PLEASE SUBMIT BILLING PACKAGES WITHIN 15 DAYS OF DELIVERY.

Submitting 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. 

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 

MODS: If any additional costs are incurred during the production of this job due to Government action (i.e. 

AAs), contractor is REQUIRED to submit written request to the Printing Specialist for written approval BEFORE 

proceeding. 

Only a warranted GPO Contracting Officer acting within their appointed limits, has the authority to issue 

modifications or otherwise change the terms and conditions of this contract. If an individual other than the GPO 

Contracting Officer attempts to make changes to the terms and conditions of this contract, you shall not proceed 

with the change and shall immediately notify the GPO Contracting Officer. Proceeding with any work not 

authorized by the GPO Contracting Officer will be at the Contractor’s own risk. 

PRODUCT: Self-Mailers 

QUANTITY: 680,000 

TITLE: FY’21 SY’21 3HSS 0421 MAILING FY’21 SY’21 4HSS 0621 MAILING

PAGES: 4 pages plus cover 

TRIM: See description

DESCRIPTION: 

THIS IS A LEVEL I PROCUREMENT PACKAGE. THIS CONTRACT IS FOR DATED MATERIAL 

AND THE DELIVERY SCHEDULE IS CRITICAL AND THEREFORE NOT NEGOTIABLE. 

***Must be printed on a press capable of printing six colors (six printing units) plus aqueous coating in a 

single pass. 

***Pantone colors cannot be build out of 4/C process, must be run as spot 5th and 6th colors. 

***All PMS color must be shown in proofs as close as possible to the actual color. 

***This is a reprint and all components MUST match to the previously printed pieces. 

***Delivery date is non-negotiable and a possible second round of proofs may be required and should be 

considered and included when bidding on project/schedule. 

***Upon completion of the printing, printer needs to provide two (2) labeled final digital downloads along 

with a directory of what was printed. 

***Second round proofs are changes to existing proofs. Corrections (color and/or copy) to be made by the 

printer and the output of the proofs need to be included in your price. 

Brochure-4 page plus cover with extended panel. 

3HSS Universal Gender (Code: FSG421) 340,000 

4HSS Universal Gender (Code: FSG621) 340,000 

TRIM SIZE: Constructed size: 5-1/2 x 8" 

Outside Cover Spread: 16-3/8 x 8 

(3 panels: 5-1/2; 5-1/2 and 5-3/8 BRC Fold in) 
Jacket 522-026: FY’21 SY’21 3HSS 0421 MAILING FY’21 SY’21 4HSS 0621 MAILING Page 4 of 9 

 

1 Inside Spread: (4 Text Pages) - Flat: 11 x 8. Final Size: 5 1⁄2” x 8” 

PRINTING/INK: 4 color process, Pantone 296 (Blue) and Pantone 187 (Red), plus Matte Aqueous Coating. 

MARGINS: Per art full bleeds on all pages. Heavy ink coverage except for extend BRC cover. 

BINDING: Score and trim 3 sides. Tuck fold extended cover inward 5-3/8 from the right trim edge. Collate cover, 

4 text papers and bind with two saddle wire stitches on the 8 side. 

WAFER SEALS: Affix 1-1/2 non-perforated clear wafer seals as position below. Wafer seals must be clear 

(match previous) with clean break for opening affixed evenly to edge of printing piece. 

Cover: 5" to 9" long at least 50-pound paper Over 9" up to 10.5" at least 60-pound paper. The front cover may be 

up to a maximum of 0.25 shorter than pages and rear cover. Place one tab on the leading and trailing edges within 

1" from the top; position one tab on the lower leading edge 0.5" from the bottom. 

Press schedule must be provided along with how many shifts this will be printed over. 

SAMPLES: FINAL SAMPLES-Printer is to supply the agency with 50 samples sealed and 50 samples not sealed 

of each version prior to shipping full run to Data Mail. 

FINAL FILES: Upon completion of the printing, printer needs to provide two (2) labeled final digital downloads 

along with a directory of what was printed. 

(These samples should be held by printer until notification has been given of office opening.) 

Shipping Address to be provided. 

RETURN OF MATERIALS: Upon completion the final digital downloads along with seven (7) samples of each 

version should be returned on or before June 4th, 20201 to: 

Ms. Jackie McGowan 

2 Maple Street 

Hartsdale, NY 10530 

GOVERNMENT TO FURNISH: Contractor to receive. All files to uploaded directly to the contractor's 

furnished FTP site. 

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

Furnish," necessary to produce the product in accordance with these specifications. 

ELECTRONIC PREPRESS: Prior to image processing, the contractor shall perform an extensive 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 GPO. 

The contractor shall create 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. 

When required by the Government, the contractor shall make minor revisions to the electronic files. It is 

anticipated that the Government will make all major revisions. 

Upon completion, the contractor must furnish final production native application files with the 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 as was originally furnished. The Government will not accept, as digital deliverables, 
Jacket 522-026: FY’21 SY’21 3HSS 0421 MAILING FY’21 SY’21 4HSS 0621 MAILING Page 5 of 9 

 

PostScript files, or any proprietary file formats other than those supplied, unless specified by the Government. 

PROOFS: When emailing, please be reminded that not all emails are entered correctly and many Government 

agencies have significant firewalls, as such a phone call to confirm receipt of email is required. 

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. Include REMINDER that agency can keep 

proof Three (3) workdays. Date of receipt is NOT considered first workday. 

Contractor must call Jennifer Brown at 757-278-8264 to confirm receipt. 

Email PDF to: jennifer.2.brown@dla.mil / jackie.mcgowan@wundermanthompson.com

AND 

2 sets of digital one-piece composite laminated halftone proofs on the actual production stock (Kodak Approval, 

Polaroid PolaProof, CreoSpectrum, or Fuji Final Proof) with a minimum resolution of 2400 x 2400 dpi. 

At contractor’s option, 1 set of inkjet proofs that are G7 profiled and use pigment-based inks may be submitted 

in lieu of digital one-piece composite laminated halftone proofs. A proofing RIP that provides an option for 

high quality color matching such as Device Links Technology and/or ICC Profiles Technology, and meets or 

exceeds industry tolerance to ISO 12647-7 standard for Graphic Technology (as of 2016 and future 

amendments) must be utilized. Proofs must be ripped and sent at plate resolution (minimum of 2400 x 2400 

dpi). If using a 1 bit tiff, the tiff must be made at a minimum of 2400 dpi. Output must be a minimum of 2400 x 

1200 dpi on a GRACoL or SWOP certified proofing media. Proofs must contain both of the following to be 

evaluated for accuracy: 3-tier color control strip: IDEAlliance ISO 12647-7 2013(i1), and the GPO Resolution 

target found www.gpo.gov/gporestarget.pdf. NOTE: If a contractor chooses this proof option, prior evaluation 

and approval of this proofing method must be provided by GPO, Quality Control for Published Products, to 

ensure that the final product will be produced in accordance with contract specifications. See instructions at: 

https://www.gpo.gov/docs/default-source/forms-and-standards-files-forendors/qlsamples6f200c30b44a64308413ff00001d133d.pdf. Failure to obtain this evaluation and approval may 

be cause for the job to be rejected should the final product not match the proofs for color. 

Proofs must contain color control bars (such as Brunner, GATF, GRETAG, or RIT) for each color of ink on the 

sheet. Control bars must be placed parallel to the press’s ink rollers and must show areas consisting of 

minimum 1/8 x 1/8” solid color patches; tint patches of 25, 50 and 75%; dot gain scale; and gray balance 

patches for process color (if applicable). These areas must be repeated consecutively across the sheet. 

The make and model number of the proofing system utilized shall be furnished with the proofs. These proofs 

must contain all elements, be in press configuration, and indicate margins. Proofs will be used for color match 

on press. Direct to plate must be used to produce the final product with a minimum of 2400 x 2400 dpi. 

AND 

***Digital color content proof shall be used to represent spot varnish. 

2 set(s) of digital color content proofs. Direct to plate must be used to produce the final product with a 

minimum resolution of 2400 x 2400 dpi. 

Proofs must be created using the same Raster Image Processor (RIP) that will be used to produce the product. 

Proofs shall be collated with all elements in proper position (not pasted up), imaged face and back, trimmed and 

folded to the finished size of the product, as applicable. 

One set of proofs to be sent to the address provided and one set to be held by contractor for reference, corrections 

and/or approvals. 
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AND 

***Stock samples (cover and text) 2 sets. 

At the same time as submission of the proofs, submit a minimum of 2, 8-1/2 x 11 blank sheets to each 

proof addressee of the actual paper to be used in the production of the contract requirements. Each 

sample must be of the kind and quality required by the specifications. The Government will rely on the 

samples only as a reference to the general appearance of the stock that will be provided by the contractor 

in conformance to the specifications. The Government assumes no contractual obligation to perform any 

inspection and test for the benefit of the contractor. The Government's failure to inspect and accept or 

reject the paper samples shall not relieve the contractor from responsibility, nor impose liability on the 

Government, for nonconforming paper. Stock samples must be approved by agency prior to printing. 

STOCK APPROVAL NOTE: Stock samples must be sent to the address provided below for approval 

PRIOR to any contractor stock procurement or use. The customer will not be held financially 

responsible for any stock procurement for this job that was not previously approved by the customer. 

***Contractor to submit ink draw downs on actual production stock of Pantone color(s) used to produce 

the product. Half of drawdown must show aqueous. Send to all specified proof addressees for approval 

PRIOR to any contractor procurement or use. 

Proofs will be held 3 working days. 

Proofs (High Resolution proof, one set of Digital Content proof, ink drawdowns for each pantone 

for each color version and stock samples), should be sent directly to: 

Ms. Jackie McGowan 

2 Maple Street 

Hartsdale, NY 10530 

The contractor must not print prior to receipt of an "OK to print." 

PRINTING: Prints in 4 color process, Pantone 296 (Blue) and Pantone 187 (Red), plus Matte Aqueous Coating 

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 

September 2019. https://www.gpo.gov/docs/default-source/forms-and-standards-files-for-vendors/vol_13.pdf 

Outside: Cover, JCP Code L50, White Matte Coated, basic weight 80lbs. 

Inside: Text, JCP A240, White Matte Coated, basis weight 80lbs. 

INK: 4 color process, Pantone 296 (Blue) and Pantone 187 (Red), plus Matte Aqueous Coating 

MARGINS: Bleed must be built. 

BINDING: Score and trim 3 sides. Tuck fold extended cover inward 5-3/8 from the right trim edge. 

Collate cover, 4 text papers and bind with two saddle wire stitches on the 8 side. 

WAFER SEALS: Affix 1-1/2 non-perforated clear wafer seals as position below. Wafer seals must be 

clear (match previous) with clean break for opening affixed evenly to edge of printing piece. 

PACKING: PACKING & SHIPPING-Self-Mailers are to be packed in separate cartons by code and shipped to: 

Data Mail, 240 Hartford Avenue, Newington, CT 06111, Attn: Colleen Costin/Scott Stickles, 860-666-0399 

SHIPPING REQUIREMENTS: All inbound materials must arrive on pallets, Pallet size: GMA1 or GMA2 
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(4-way), length: 48 inches, width: 40/42 inches, Maximum height per pallet: 48 inches, Maximum weight per 

pallet: 2,500 pounds, Maximum weight per carton: 45 pounds. 

LABELING AND MARKING: (Package and/or Container label): Each package or carton must be labeled. The 

label MUST indicate full title, quantity, Jacket number, and total number of boxes shipped, i.e. 6 of 10. White 

labels with black image of bold, 1/4" height entries. Inner packages require labels 

 

DEPARTMENTAL RANDOM COPIES (BLUE LABEL): All orders must be divided into equal sublots in 

accordance with the chart below. 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 the copies were selected as 

directed using GPO Form 917 – Certificate of Selection of Random Copies which can be located on GPO.gov. 

The random copies constitute a part of the total quantity ordered, and no additional charge will be allowed. 

Quantity Number of 

 Ordered Sublots 

 680,000 200 

 

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

Departmental Random Copies (Blue Label), which 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.

A copy of the print order/specification and a signed Certificate of Selection of Random Copies must be included. 

A copy of the signed Certificate of Selection of Random Copies must accompany the invoice sent to U.S. 

Government Publishing Office, Financial Management Service, for payment. Failure to furnish the certificate 

may result in delay in processing the invoice. 

SCHEDULE: Purchase Order and furnished material will be emailed no later than March 24, 2021. 

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

furnished with the 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. 

Inside delivery by April 20, 2021 by 2pm local time 

NOTIFICATION OF SHIPMENT: Contractor must notify the ordering agency on the same day that the 

product ships/delivers via e-mail sent to jennifer.2.brown@dla.mil / jackie.mcgowan@wundermanthompson.com

and lulerio@gpo.gov. The subject line of this message shall be Distribution Notice for Jacket 522-026. The notice 

must provide all applicable tracking numbers, shipping method, and Title. Contractor must be able to provide 

copies of all delivery, mailing, and shipping receipts upon agency request. 

DISTRIBUTION: 

Shipping costs need to be included in the bid price. 

Deliver f.o.b. destination as follows: 

Deliver final product including Blue Label copies to: 

Data Mail, 

240 Hartford Avenue 

Newington, CT 06111 

Attn: Colleen Costin/Scott Stickles, 860-666-0399 

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

these specifications: 
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Product Quality Levels: 

 (a) Printing Attributes -- Level I. 

 (b) Finishing Attributes -- Level I. 

Inspection Levels (fromANSI/ASQC 21.4): 

 (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 Approved stock samples 

P-9. Solid or Screen Tints Color Match Approved proofs/ Pantone Matching System 

P-10. Four Color Process Approved proofs 

Prior to award, contractor may be required to provide information related to specific equipment that will be used 

prior to production. 
Jacket 522-026: FY’21 SY’21 3HSS 0421 MAILING FY’21 SY’21 4HSS 0621 MAILING Page 9 of 9 

 

Bidders must fill out this page and return it. 

Jacket 522-026: TOTAL BID PRICE $_________________ ADDITIONAL RATE $__________ PER 1,000 

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

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

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 points(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. 

 

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

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 fax or mail, fill out and return one 

copy of Page 6, initialing/signing where indicated. 

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

Bidder __________________________________________________________________________ _________ 

 (Contractor 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) 

COMPLETE THIS PAGE AND SUBMIT AS YOUR BID 

 ******************************************************************************************* 

THIS SECTION FOR GPO USE ONLY 

Certified by:__________ Date:___________ Contracting Officer:__________ Date:___________ 

 (Initials) (Initials) 

*******************************************************************************************