Fillable PUR-CR PUR CR 9-4.pdf

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PUR-CR PUR CR 9-4.pdf

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PUR-CR
CONT
RACTOR INFORMATION
REQUISITION #:
FRM-U505.C&D.01 (Revised 7/1/16)
Contractor or Individual Name:
Please answer the following questions:
1. Is the Contractor using a current employee of a Louisiana state agency or state university, other than LSU,
in the performance of this contract?
Yes No
If yes, please enter the following information:
Employee:
Agency or University:
Job Title:
2. Is the Contractor a legal entity, a child, spouse, brother, spouse of brother, sister, spouse of sister, parent,
spouse of parent, or parent of spouse of an LSU employee who will take part, or share responsibility, for
action of LSU through approval, disapproval, decision, recommendation, rendering advice, investigation or
failure to act or perform a service with respect to the proposed contract?
Yes No
3. Do you, or any of the individuals listed above have ownership interest in the Contractor?
Yes No
4. Is the Contractor a Non-Resident Alien (Not a US Citizen)?
Yes No (N/A if Contractor is a company)
If yes, contact Accounts Payable Office for requirements (578-1550). Compliance with FASOP: AS-04 is
required and must be met prior to contracting. Available on the internet at:
http://www.lsu.edu/administration/ofa/fasops/FASOPAS04.pdf
5. Is the Contractor a current LSU employee or does an LSU employee have an ownership interest in the
Contractor?
If yes, attach a completed PM-11 or PM-67. Yes No
6. Will the Contractor employ a current LSU employee? Yes No
If yes, attach a completed PM-11 or PM-67.
7. Has the Contractor been an employee of LSU in the past two years? Yes No
8. Is the Contractor a current or retired member of Teachers Retirement System of LA?
If yes, contact Payroll Office - 578-3321
Yes No
9. Will the Contractor perform work within the State of Louisiana for more than 30 days of the contract term?
Yes No
If yes and the Contractor is a Corporation, Contractor will be required to register with the LA Secretary of
State's Office. See http://www.sos.la.gov/BusinessServices/FileBusinessDocuments/Pages/default.aspx
.
PAYMENT TERMS
10. Will travel expenses be reimbursed to the Contractor? Yes No
PUR-CR
CONTRACTOR INFORMATION
Page 2
FRM-U505.C&D.01 (Revised 7/1/16)
11. Wil
l travel expense be paid to others on the Contractor’s behalf, such as Lod Cook?
If yes: Yes No
• What is the estimated amount?
• Attach a copy of the AS516 to the requisition.
See http://www.lsu.edu/administration/ofa/oas/acctpay/pdfs/as516.pdf
If this contract exceeds $50,000, a justification for the selection of this contractor must be attached.
12. Is this contract funded from State funds? Yes No
If yes, what amount should be paid in each fiscal year?
Fiscal Year Amount
Fiscal Year Amount
Fiscal Year Amount
Fiscal Year Amount
13.
How will services be paid to the Contractor?
$ Hourly; $ Daily; $ Weekly; $ Monthly
Multiple installments based on specific time frames (must provide date/amounts of payments below
or as an attachment)
Multiple installments based on completion of tasks (must provide details/amounts/tasks/dates below
or
as an attachment)
The total
of payment installments must equal the maximum amount entered on the requisition.
Payment Details:
14. This is the information used to contact the Contractor for contract signature or forms.
Supplier Contact Name:
Company Name:
Address Line 1:
Address Line 2:
City: State: Zip Code:
Phone Number: Email:
COST CENTER MANAGER
Name: Department:
Address:
City: State: Zip Code:
One lump sum payment upon completion of services
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Completed 19 February 2020

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