Fillable STATEMENT AND ACKNOWLEDGMENT (Los Alamos National Laboratory)

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STATEMENT AND ACKNOWLEDGMENT (Los Alamos National Laboratory)

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STATEMENT AND ACKNOWLEDGMENT
OMB Control Number: 9000-0014
Expiration Date: 12/31/2017
PART I - STATEMENT OF PRIME CONTRACTOR
1. PRIME CONTRACT NO. 2. DATE SUBCONTRACT
AWARDED
3. SUBCONTRACT NUMBER
15b. TITLE OF PERSON SIGNING
AUTHORIZED FOR LOCAL REPRODUCTION
PREVIOUS EDITION IS NOT USABLE
STANDARD FORM 1413 (REV. 4/2013)
Prescribed by GSA/FAR (48 CFR) 53.222(e)
4. PRIME CONTRACTOR 5. SUBCONTRACTOR
a. NAME a. NAME
b. STREET ADDRESS b. STREET ADDRESS
c. CITY d. STATE e. ZIP CODE c. CITY d. STATE 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 subcontractor acknowledges that the following clauses of the contract shown in Item 1 are included in this 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
14. NAME(S) OF ANY INTERMEDIATE SUBCONTRACTORS, IF ANY
A
C
B
D
15a. NAME OF PERSON SIGNING
16. BY (Signature)
17. DATE SIGNED
PAPERWORK REDUCTION ACT STATEMENT: Public reporting burden for this collection of information is estimated to average .05 hours per response, including the time for
reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments
regarding this burden estimate or any other aspects of this collection of information, including suggestions for reducing this burden, to U.S. General Services Administration,
Regulatory Secretariat (MVCB)/IC 9000-0014, Office of Governmentwide Acquisition Policy,1800 F Street, NW, Washington, DC 20405.
DE-AC52-06NA25396
Los Alamos National Security, LLC.
PO Box 1663, MS M873
Los Alamos
87545
NM
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STATEMENT AND ACKNOWLEDGMENT (Los Alamos National Laboratory)

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Completed 6 August 2020

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