MILITARY INTERDEPARTMENTAL PURCHASE REQUEST

1.

PAGE 1 OF PAGES

2. FSC 3. RFQ REF/CONTROL NO. 4. DATE PREPARED 5. MIPR NUMBER 6. AMEND NO.

FUNDS EXPIRATION DATE: PRIORITY: DATE MATERIAL REQD: 

7. TO: 8. FROM:

9.

ITEMS ARE ARE NOT INCLUDED IN THE INTERSERVICE SUPPLY SUPPORT PROGRAM AND REQUIRED INTERSERVICE

SCREENING HAS HAS NOT BEEN ACCOMPLISHED.

ITEM

NO.

a

DESCRIPTION

(Federal stock number, nomenclature, specification and/or drawing No., etc.)

B

QTY

C

UNIT

d

ESTIMATED

UNIT

PRICE

e

ESTIMATED

TOTAL

PRICE

f

NOTE TO CONTRACTING OFFICER: “THIS ORDER MEETS ALL TERMS, CONDITIONS & RESTRICTIONS DICTATED BY THE FUNDING SOURCE

“THIS FUNDS TRANSFER TO DLA IS EXECUTED UNDER THE AUTHORITY OF DFARS PGI 208.7006, DLA ASSIGNMENTS."

10. SEE ATTACHED PAGES FOR DELIVERY SCHEDULES, PRESERVATION AND PACKAGING INSTRUCTIONS, SHIPPING 

INSTRUCTIONS AND INSTRUCTIONS FOR DISTRIBUTION OF CONTRACTS AND RELATED DOCUMENTS

11. GRAND TOTAL

12. TRANSPORTATION ALLOTMENT (Used if FOB Contractor's plant)

FOR DETAILS CONTACT: COMM (805) 982-XXXX, DSN 551-XXXX

(BILLING) 

(ADMIN) 

(TECH) 

(DATA, DD 1423)

13. MAIL INVOICES TO (Payment will be made by)

PAY OFFICE DODAAD

14. FUNDS FOR PROCUREMENT ARE PROPERLY CHARGEABLE TO THE ALLOTMENTS SET FORTH BELOW, THE AVAILABLE BALANCES OF WHICH ARE 

SUFFICIENT TO COVER THE ESTIMATED TOTAL PRICE.

ACRN APPROPRIATION LIMIT/

SUBHEAD

SUPPLEMENTAL ACCOUNTING CLASSIFICATION ACCTG 

STA

DODAAD

AMOUNT

AA

15. AUTHORIZING OFFICER (Type name and title) 16. SIGNATURE 17 DATE 

DD FORM

1 JUN 72 448 PREVIOUS EDITION WILL BE USED UNTIL EXHAUSTED.

ORDERING DODAAC:

(Agency, name, telephone number of originator)
ACCEPTANCE OF MIPR

1. TO (Requiring Activity Address) (Include ZIP Code) 2. MIPR NUMBER 3. AMENDMENT NO.

BASIC

4. DATE (MIPR Signature Date) 5. AMOUNT (As Listed on the MIPR)

6. The MIPR identified above is accepted and the items requested will be provided as follows: (Check as Applicable)

a. ALL ITEMS WILL BE PROVIDED THROUGH REIMBURSEMENT (Category I)

b. ALL ITEMS WILL BE PROCURED BY THE DIRECT CITATION OF FUNDS (Category II)

c. ITEMS WILL BE PROVIDED BY BOTH CATEGORY I AND CATEGORY II AS INDICATED BELOW

d. THIS ACCEPTANCE, FOR CATEGORY I ITEMS, IS QUALIFIED BECAUSE OF ANTICIPATED CONTINGENCIES AS TO FINAL PRICE.

CHANGES IN THIS ACCEPTANCE FIGURE WILL BE FURNISHED PERIODICALLY UPON DETERMINATION OF DEFINITIZED PRICES, BUT

PRIOR TO SUBMISSION OF BILLINGS.

7.

MIPR ITEM NUMBER(S) IDENTIFIED IN BLOCK 13, “REMARKS” IS NOT ACCEPTED (IS REJECTED) FOR THE REASONS INDICATED

8. TO BE PROVIDED THROUGH REIMBURSEMENT

CATEGORY I

9. TO BE PROCURED BY DIRECT CITATION OF FUNDS

CATEGORY II

ITEM NO.

a

QUANTITY

B

ESTIMATED PRICE

C

ITEM NO.

a

QUANTITY

b

ESTIMATED PRICE

C

ACCOUNTING DATA: 

d. TOTAL ESTIMATED PRICE d. TOTAL ESTIMATED PRICE

10. ANTICIPATED DATE OF OBLIGATION FOR CATEGORY II ITEMS 11. GRAND TOTAL ESTIMATED PRICE OF ALL ITEMS

12. FUNDS DATA (Check if Applicable)

a. ADDITIONAL FUNDS IN THE AMOUNT OF $ ARE REQUIRED (See Justification Block 13)

b. FUNDS IN THE AMOUNT OF $ ARE NOT REQUIRED AND MAY BE WITHDRAWN

13. REMARKS

14. ACCEPTING ACTIVITY (Complete Address)

DIRECTOR OF PROCUREMENT

DLA TROOP SUPPORT

700 ROBBINS AVENUE

ATTN: FCD/HEPP

PHILADELPHIA, PA 19111-5096

15. TYPED NAME AND TITLE OF AUTHORIZED OFFICIAL

16. SIGNATURE 17. DATE

DD FORM

1 JUL 71 448-2 PREVIOUS EDITION WILL BE USED UNTIL EXHAUSTED.