Fillable Form 6.: STATEMENT AND ACKNOWLEDGMENT (National Renewable Energy Laboratory)

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Form 6.: STATEMENT AND ACKNOWLEDGMENT (National Renewable Energy Laboratory)

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STATEMENT AND ACKNOWLEDGMENT
PART I - STATEMENT OF PRIME CONTRACTOR
1. PRIME CONTRACT NO.
2. DATE SUBCONTRACT
AWARDED
3. SUBCONTRACT NUMBER
4. PRIME CONTRACTOR 5. SUBCONTRACTOR
a. NAME
a. NAME
b. STREET ADDRESS
b. STREET ADDRESS
c. CITY
d. STATE
e. ZIP CODE
c. CITY
e. ZIP CODE
6.
The prime contract does, does not contain the clause entitled "Contract Work Hours and Safety Standards Act --
Overtime Compensation."
7.
The prime contractor states that under the contract shown in Item 1, a subcontract was awarded on the date shown in Item 2 to the
subcontractor identified in item 5 by the following firm:
a.
NAME OF AWARDING FIRM
b.
DESCRIPTION OF WORK BY SUBCONTRACTOR
8. PROJECT
9. LOCATION
10a. NAME OF PERSON SIGNING
11. BY (Signature)
12. DATE SIGNED
10b. TITLE OF PERSON SIGNING
PART II - ACKNOWLEDGMENT OF SUBCONTRACTOR
13. The lower-tier subcontractor (at any –tier) acknowledges that the following clauses of the subcontract shown in Item 1 are included in their
lower-tier subcontract:
• Contract Work Hours and Safety Standards Act - Overtime
Compensation (If included in prime contract see Block 6)
• Payrolls and Basic Records Withholding of Funds
• Disputes Concerning Labor Standards
• Compliance with Construction Wage Rate Requirements
and Related Regulations
• Construction Wage Rate Requirements Apprentices and
Trainees
• Compliance with Copeland Act Requirements
Subcontracts (Labor Standards)
• Contract Termination - Debarment Certification of Eligibility
• Clauses Applicable to Subcontractors that Require
Performance on NREL-Operated Facilities
14. NAME(S) OF ANY INTERMEDIATE SUBCONTRACTORS, IF ANY
AUTHORIZED FOR LOCAL REPRODUCTION
PREVIOUS EDITION IS NOT USABLE
NREL Site Specific Clauses (5/22/2015)
Derived from GSA STANDARD FORM 1413 (REV. 4/2013)
Prescribed by GSA/FAR (48 CFR) 53.222(e)
B
D
16. BY (Signature)
A
C
15a. NAME OF PERSON SIGNING
17. DATE SIGNED
15b. TITLE OF PERSON SIGNING
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Form 6.: STATEMENT AND ACKNOWLEDGMENT (National Renewable Energy Laboratory)

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Completed 19 July 2020

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