Department of Veterans AffairsOffice of Acquisition and Logistics National Acquisition CenterP.O. Box 76Hines, IL60141 NOV 10,2008In Reply Refer To:

Mr. Julian Ross

OxySure Systems, Inc.

10880 John W. Elliott Road, Suite 600

Frisco, TX 75034

 

Dear Mr. Ross:

 

Enclosed is a copy of your Federal Supply Schedule Contract V797P-4153b effective November 15, 2008 through November 14, 2013 for items awarded under Solicitation Number RFP 797-FSS-99-0025-R5. This letter outlines the initial requirements of your newly awarded contract and also provides information on several clauses that you should be aware of for future contract actions.

 

 

You are required to file a VETS-100 report with the Department of Labor (DOL) by September 30th annually. The contractor is required to contact the Department of Labor by phone at ###-###-#### or website http://www.vet.s100.com to obtain the necessary information to complete the VETS-100 report (this website is best viewed using Internet Explorer 6.0 or above).

 

Contractors must also renew their Central Contractor Registration (CCR) once a year or the CCR database will cancel the registration. It is noted that OxySure Systems, Inc's registration is valid until July 11, 2009.   You may renew and update your CCR registration at: http://www.ccr.gov.

 

 

As the estimated value of this contract exceeds $50,000 and your firm employs more than 50 your firm is required to develop and maintain a written Affirmative Action Plan (AAP) for each of its establishments within 120 days of contract award. You may seek technical assistance from the Office of Federal Contract Compliance Programs (OFCCP) at http://www.dol.gov/esa/ofccp/: this website provides useful contact information as well as a sample AAP for your reference.

 

The AAP is to be kept on file and implemented by the contractor - you are not required to submit it to the OFCCP unless they request it for the purpose of a compliance review; however, it is requested that you provide this office with confirmation of your compliance via fax or email.

 

 

 

1  FAR 52.222-37 Employment Reports on Disabled Veterans and Veterans of the Vietnam Era (Title 38 Section 4212)

2  Affirmative Action (AA) Compliance (41 CFR 60-1 & 60-2)(52.212-3(d))

 

 

 

Contract Clause l-FSS-600, Contract Price Lists (pages 58-62 of your contract) requires you to prepare a VA Federal Supply Schedule Contract Price List for approval. Please carefully read and comply with the instructions covering the content and format of the VA FSS contract price list as stipulated in subparagraphs (2) and (3) (page 59) of this clause. Your VA FSS contract price list must contain all the information required and must be presented in the required format. If you choose to use your commercial catalog as your VA FSS contract price list all non-accepted/awarded items must be lined out or deleted and presented in acceptable manner determined by the Contracting officer. Please note that the use of this Government contract to solicit Government business for non-contract products is fraudulent and subject to prosecution.

 

Carefully read and comply with Clause l-FSS-600, Contract Price Lists subparagraph (5)3. This subparagraph requires that "proof copies of your Federal Supply Schedule Contract Price List, including cover letters, be submitted in duplicate to the Contracting Officer for review and approval prior to its formal printing and distribution. This action must be accomplished within 30 days after the date of award. Upon approval, one "proof copy will be returned to you with further instructions for formal printing and distribution. Failure to follow these instructions may cause you to reprint your FSS price list.

 

■      NAC-CM Pricelist

 

The contractor is also responsible for maintaining the NAC-CM database - a blank database template and instructions for completion shall be provided at time of contract award. Note that this database must be completed within 30 days after date of award and must be updated when the contract is modified.

 

■      GSA Advantage! Pricelist

 

In partnership with the General Service's Administration (GSA), VA will now maintain product data in GSA's online electronic ordering system, GSA Advantage! (pages 57-58). The VA/GSA Partnership now makes it possible for authorized VA Federal Supply Schedule (FSS) contractors to submit quickly and easily their contract product and pricing information electronically and for Federal government offices to shop and order via the Internet. Creating and submitting electronic catalogs (ECATs) is easy and at near zero cost using GSA's Schedule Input Program (SIP). Likewise, there is no additional charge to contractors or Federal government offices for orders placed through GSA Advantage! You may download the most recent release of the SIP by visiting http://vsc.fss.gsa.gov and linking to the "SIP Vendors" Section (at the top of the page). You have the choice of using SIP and the enclosed Start-up Kit, or you may make the decision to publish your contract information on GSA Advantage through third-party services. These companies charge a fee for their services.

 

This action must also be completed within 120 days after the date of award. Ordering facilities utilize the GSA Advantage program to search for and purchase products; therefore, it behooves you to complete these actions in a timely manner to make your products available for immediate purchase.

 

 

The "PO Portal" is a new website developed by GSA that allows you to easily view and print your GSA Advantage purchase orders. This site also allows you to download your orders in a number of formats including XLS, TXT, XML, or PDF. In addition, the PO Portal allows you to track your orders by submitting a status request to your customer via GSA Advantage. The PO Portal is available at https://www.poportal.qsa.gov.

 

3 I have included this specific text and a sample document for your reference.

 

 

Contract Clause 552.238-74, Industrial Funding Fee and Sales Reporting (pages 63-64), requires that you submit, on a quarterly basis, the dollar value (in U.S. dollars and rounded to the nearest whole dollar) for all sales under the contract during the preceding 3-month period, to include any partial month. This report is required for each Special Item Number (SIN) under which you have been awarded items. The GSA Form 72, Contractor's Report of Sales provided with the award package, may be reproduced.

 

Reports are due on or before the 60th day following the completion of each quarter of the contract

(any partial month is to be considered as one month for reporting purposes). Sales for orders that extend beyond the contract period will be reported within 30 days of final payment.

 

 

The Government reserves the right to inspect, without further notice, such records that pertain to sales under this contract. Further failure or refusal to furnish the required reports or falsification thereof, will constitute cause for terminating the contract for default in accordance with the provisions of your contract.

 

Contract Clause 552.238-74, Industrial Funding Fee and Sales Reporting, also requires that you pay the Department of Veterans Affairs (DVA) an Industrial Funding Fee (IFF) at the end of each contract quarter. The IFF shall be submitted at the same time as the GSA Form 72, Contractor's Report of Sales. The IFF equals 0.50% (one-half of one percent) of the total sales reported on the GSA Form 72. The IFF reimburses the DVA for the costs of operating portions of the Federal Supply Schedule Program and recoups its operating costs for ordering activities. This fee is included in the awarded price(s) and reflected in the total amount charged to ordering activities. Remittance for the IFF and your GSA Form 72 shall be submitted to our Fiscal Division. Remittance and Contractor's Reports of Sales should be addressed to:

 

Department of Veterans Affairs

C/O FSS Service (001AL-A2-2)

P.O. Box 76

Hines, IL 60141

 

The IFF amount due shall be paid by check or electronics funds transfer to the "Department of Veterans Affairs". Where multiple SIN(s) and/or contracts are involved, the IFF may be consolidated into one check. To ensure that the payment is credited properly, the Contractor should identify the check or electronic transmission as an "Industrial Funding Fee" and include the following information: contract number(s), report amount(s), and report period(s).

 

(1)	If the IFF payment is made by check, it shall be forwarded to the address indicated above.

(2)	If the IFF payment is to be made by electronic funds transfer through the Automated Clearing House (ACH), please refer to Clause 52.232-33 Payment by Electronic Funds Transfer - Central Contractor Registration, paragraph (c) for further instructions.

 

IFF Payments shall be made via ACH Electronic Transfer of Funds using the following information:

 

	Receiver Information
	Company Name Street Address or P.O. Box City, State, Zip Code Company Contact Contact Phone Federal Taxpayer ID Number	Department of Veterans Affairs P.O. Box 7005 Hines, IL 60141 Annette Crayton 708 ###-###-#### 74 1612229

 

NOTE: A report is required even when no sales occur during the reporting period.

 

NOTE: Vendor's sales report must include all Prime Vendor, Direct-to-Patient Distribution, and Department of Defense Distribution and Pricing Agreement (DAPA) program sales, as applicable.

 

If the full amount of the IFF is not paid within 60 calendar days after the end of the applicable reporting period, it shall constitute a contract debt to the United States Government under the terms of FAR 32.6. The Government may exercise all rights under the Debt Collection Act of 1982, including withholding or setting off payments and interest onto the debt (see FAR 52.232-17, Interest). Failure to submit sales reports, falsifications of sales reports and/or failure to pay the IFF in a timely manner may result in termination or cancellation of this contract. Willful failure or refusal to furnish the required reports, falsification of sales reports, or failure to pay the IFF in a timely manner constitutes sufficient cause to terminate this contract under FAR 52.212-4, paragraph (m) "Termination for Cause" (page 16).

 

In accordance with 552.243-72 Modifications (Multiple Award Schedule) (JUL 2000) (ALT I - SEP 1999) (page 64-66) contract modifications may be requested by the awardee at any time throughout the term of the contract. At a minimum every request shall describe the proposed change(s) and provide the rationale for the requested change(s). The Modification Request Form (a copy of which is enclosed with this award package) provides instructions on how to request, and what is required for the following types of modification actions:

 

The effective date of the modification will occur on the 1st or 15th of the month.

 

Contractors are reminded that they must update their electronic pricelists (including the NAC-CM database and GSA Advantage!) and provide the CO with an updated paper pricelist for approval after receiving an executed copy of the requested modification.

 

 

Pursuant to 552.216-70 Economic Price Adjustment - FSS Multiple Award Schedule Contracts (SEP 1999) (ALT 1 - SEP 1999) (Local Deviation) (pg 66-67) contractors may request price increases when the following conditions are met:

-	Increases result from a reissue or other modification of the Contractor's commercial catalog/pricelist that was used as the basis for contract award.

-	Increases are requested before the last 60 days of the contract period.

-	At least 30 days elapse between requested price increases.

 

The tracking customer's price must be disclosed with your request for increase. Note that the awarded tracking customer and the established ratio at the time of award will affect your ability to receive an increase.

 

The government reserves the right to accept the price increase as requested; negotiate better discount; or refuse the requested increase and remove the product(s) from the contract pursuant to the Cancellation clause of the contract.

 

 

In accordance with 552.238-75 Price Reductions (MAY 2004) (page 63-65) the contractor shall report all price reductions provided to the tracking customer within 15 days after the effective date of the reduction. A price reduction occurs if the contractor:

 

-	Reduces awarded contract pricing by revising the commercial catalog, pricelist, schedule upon which contract award was predicated.

-	Grants more favorable discounts or terms and conditions to the awarded tracking customer.

-	Grants special discounts to the tracking customer and the change disturbs the price/discount relationship of the government to the tracking customer.

 

Contractors are able to offer ad hoc discounts to the government without disturbing the tracking customer ratio. In addition, contractors are not required to pass on price reductions/special discounts provided to commercial customers other than the specified tracking ratio customer.

 

 

The FSS contract number or other authorization for supplies delivered or services performed (including order number and contract line number) must be clearly identified on all invoices. In addition, all correspondence and documents pertaining to the contract shall be noted with the contract number.

 

 

As appropriate, when goods are shipped to an ordering activity you are required to furnish to that activity, two (2) copies (unless otherwise specified in your contract) of a manual, handbook or brochure containing operation, installation and maintenance instructions (including pictures or illustrations, schematics and complete repair/test guides) as necessary. Where applicable, it will include electrical data and connection diagrams for all utilities. The instructions shall also contain a complete list of all replaceable parts showing parts showing part number, name and quantity required.

 

Products manufactured to metric dimensions will be considered on an equal basis with those manufactured using inch-pound units, providing they fall within the tolerances specified using conversion tables contained in the latest revision of Federal Standard No. 376 and all other requirements of this document are met.

 

 

Finally, you are required to place the enclosed posters describing the Equal Employment Opportunity Act and the Fair Labor Standards Act in a prominent location for the duration of your contract.

 

The information in this letter and the documents referenced below are available the Medical Equipment & Supplies website: http://www1.va.gov/oamm/oa/nac/fsss/medequipsupfss.cfm.

 

Thank you in advance for your attention in these matters. If you have any questions, you may contact the undersigned at ***@*** or ###-###-####.

 

 

Sincerely,

 

 

Enclosures:

1. Award/Contract (SF 1449)

2. Awarded Price List

3. Sample Paper Pricelist

4. GSA Advantage Start-Up Package

5. GSA Advantage Purchase Order Portal

6. GSA Form 72

7. Modification Request Form

 

OxySure Systems, Inc.

Contract Number V797P-4153b

SUMMARY OF AWARD Addenda to SF 1449

 

 

(a)   FAR 52.212-4 Contract Terms and conditions - Commercial Items and Addenda

 

 

 

(d)   Revisions: Solicitation page 116 (7/24/08 & 9/18/08); and Solicitation page 117 (9/18/08).

 

(e)   Final Proposal Revision (FPR> Letter dated November 6, 2008.

 

 

 

 

 

(a)   Contract period of: November 15, 2008 through November 14, 2013

 

(b)   Discounts as identified on above cited Price List by Special Item Number (SIN) and /or Models and Maximum Order:

 

SIN                                                      Awarded Maximum Order

 

A-49                                                    $100,000

 

Product Number                                Basic Discount

615-00                                                    7.8%

615-01                                                  11.5%

615-03                                                  22.0%

615-04                                                  20.0%

615-05                                                    7.2%

 

(c) Minimum Order:                           None

OxySure Systems, Inc. Contract Number V797P-4153b

 

(d)   Quantity Discount: Additional 3% taken off the FSS net price when 100 or more (mix or match) items are purchased.

 

(e)   Delivery Time: Within 30 days After Receipt of Order (ARO)

 

(f)    Expedited Delivery: Within 3 days After Receipt of Order (ARO). Government is responsible for the additional shipping charges between the normal surface rate and the expedited rate.

 

(g)   Prompt Payment: 1% 20 days, net 30

 

(h)   F.O.B. Destination Point(s): FOB Destination 48 contiguous States and the District of Columbia and point of exportation to destination in Alaska, Hawaii and Puerto Rico.

 

(i)    Warranty Provision: As stated in the attached Limited Warranty Information dated October 2008 consisting of three (3) pages.

 

(j)    Return/Exchange Goods Policy:

 

1.    Before any product may be returned, a Return Materials Authorization (RMA) Number must be secured. The RMA number can only be issued by OxySure's Customer Service. To assist in the return process, the ordering facility is required to provide Customer Service the following information:

(a)   OxySure Product Code and Lot Number

(b)  Quantity Customer wishes to return

(c)   Order Number Associated with the Product(s)

(d)  OxySure's Original Invoice Number

(e)   Reasons for Return

2.    All products returned shall be shipped to OxySure, freight prepaid, unless the return is due to OxySure error, such determination being made is the sole discretion of OxySure. On all international returns, OxySure will specify the method of shipment.

 

3.     Items eligible for full credit:

(a)   Products shipped in error

(b)   Products ordered in error, if authorized for return within thirty (3) days of receipt

(c)   Defective Products due to OxySure workmanship

 

4.     Items not eligible for return:

(a)   Custom products or products sold on a "No-return" basis

(b)   Goods held over ninety (90) days from the original invoice date

(c)   Partial cases or quantities less than minimum order quantity

(d)   Products unsalable due to re-design, preprocessing, revision, or obsolescence

(e)   Demonstration products

(f)   Products no longer in their original packaging, used, or damaged through no fault of OxySure

 

5.    A 15% Restocking Fee will be assessed on all returns authorized over thirty (30) days after the original invoice date.

 

OxySure Systems, Inc.

Contract Number V797P-4153b

 

(k) Tracking Customer: In accordance with the Price Reduction Clause 552.238-72, the Government and OxySure Systems, Inc agree that City of Frisco is the identified tracking customer for whom the contract award is predicated. During the course of this contract, for any sales under the Maximum Order, the net price for any awarded item is reduced to the identified tracking customers the Government net price will be reduced proportionately.

 

The established ratios are shown on the attached spreadsheet titled Discount Relationship (Government Price vs. Most Favored Customer (MFC) Price) Ratio dated November 6, 2008 consisting of one (1) page.

 

(I) Annual Rebate: 1% annual rebate for sales under the contract that exceeds $500,000.00

 

(m) Exceptions: None

 

The lettered sections (a), (b), (c), (d), (e), (f), (g), (h),(i), and (j) above under "Terms and Conditions as agreed to" are required in the "Information for Ordering Activities" section of your Published Federal Supply Schedule Pricelist.

 

Your tax I.D. number is required to be included on the Published Price List to facilitate payment by ordering activities.

* List Prices are FOB Frisco (OxySure's Headquarters), and include shipping charges.

 

 

 

 

OxySure® Model 615 Portable Emergency Oxygen System. Using OxySure's patented and revolutionary "oxygen from powder" technology, the OxySure® Model 615 produces medically pure oxygen for use BY A LAYPERSON in any medical emergency, prior to the first responders arriving on the scene. Just like an AED, Model 615 bridges the gap between the onset of an emergency and the time that the first responders arrive on the scene. It is safe for public display/storage and layperson use, requires no training and uses a simple 2-step actuation. Model 615 has been approved by the FDA for over-the-counter sale (no need for prescription or standing orders). The OxySure Model 615 system comes ready to be placed in service and includes a mask and OxySure's custom designed delivery tubing, both neatly stored in a custom plastic tray under the green cover. The system is reusable with Replacement Cartridges. See www.oxysurestore.com

 

Product Specifications: Height: 12" (30.5 CM) | Width: 10" (25.4 CM) | Depth: 6" (15.2 CM) | Weight: 11 lbs. Exposure Limits: Between 40°F and 160°F | Storage: Between 70°F and 86°F (Room Temperature) Oxygen Volume: 90+ standard liters | Shelf Life: 2 Years Approvals: FDA Clearance for Over-the-Counter Sale (no prescription or standing orders required)

$333.91

 

OxySure® Model 615, Disposable Replacement Cartridge                                                                                        Product No. 615-01

 

 

 

OxySure® Model 615

© 2008 OxySure® Systems, Inc. All Rights Reserved Worldwide.

 

Disposable Cartridge: The OxySure® quality limited warranty lasts for 2 years in the case of the disposable cartridge or until it is used, whichever happens sooner.

 

Reusable Housing: The OxySure quality limited warranty lasts for 3 years in the case of the reusable housing or 25 uses, whichever happens first.

 

What will OxySure® do to correct the problem?

 

OxySure® will examine the product and decide, at its sole discretion, if it's covered under this limited warranty. OxySure® will then, at its sole discretion, either repair the defective product or replace it with the same or a comparable product. In these cases, OxySure® will pay for the cost of replacements, repairs, spare parts, labor and shipping costs, if and where applicable. This does not apply to any repair work or replacement not expressly authorized by OxySure® in writing. Replacement parts, if any, become the property of OxySure®. If the item is no longer sold by OxySure®, OxySure® will provide an appropriate replacement. It is OxySure® that, in its sole discretion, determines what constitutes an appropriate replacement. THIS REMEDY SHALL BE YOUR SOLE AND EXCLUSIVE REMEDY FOR ANY BREACH OF WARRANTY.

 

 

The limited warranties are valid from original date of acceptance by the end user of the product. The original purchase receipt or purchase order, together with proof of payment (if applicable) is required as proof of purchase.

 

The limited warranties do not apply to normal wear and tear of products or to products that have been stored or shipped incorrectly, including storage or shipment under environmental conditions outside of those conditions specified by OxySure®. Furthermore, the limited warranties do not apply to products that have been used inappropriately, abused, misused, altered, or cleaned with incorrect cleaning methods or incorrect cleaning products. The limited warranties do not cover normal wear and tear, cuts or scratches, or damage caused by impacts or accidents. The limited warranties do not cover defects in appearance, cosmetic, decorative items or any non-operative parts. The limited warranties do not apply if the product serial number has been removed, defaced or altered. Further, the limited warranties are not applicable if the products have been stored outdoors or in humid environments, or if the products have been otherwise not stored at room temperature.

 

Warranty coverage terminates if the original purchaser sells or otherwise transfers the product, unless the original purchaser is an authorized distributor of OxySure products; in such event, coverage is transferred to the original customer of such distributor (the"end user"). Warranty coverage also terminates if the end user sells or otherwise transfers the product. No OxySure reseller, agent, or employee is authorized to make any modification, extension, or addition to this warranty.

 

Some states and provinces do not allow the limitation or exclusion of incidental or consequential damage, so this limitation may not apply to you.

 

 

To be able to claim the limited warranty you need to follow the specific instructions for the products, including, but not limited to, the "Instructions for Use".

 

 

This limited warranty gives you specific legal rights, and you may also have other rights that vary from country to country, state to state or province to province.

 

 

No product may be returned directly to OxySure® without first contacting OxySure® for a Return Material Authorization ("RMA") number. If it is determined that the product may be defective, you will be given an RMA number and instructions for product return. An unauthorized return, i.e. one for which an RMA number has not been issued, may be returned to you at your expense. Authorized returns are to be shipped prepaid and insured to the address on the RMA in an approved shipping container. Your original box and packaging materials should be kept for storing or shipping your product. To obtain warranty service, an original purchase receipt or purchase order, together with proof of payment (if applicable) is required as proof of purchase. OxySure® retains the exclusive right to either repair or replace the unit at its sole discretion.

 

 

STEP 1: Contact OxySure® Customer Service to receive a RMA number.

 

Call or e-mail OxySure® Customer Service to describe the problem you are experiencing and request a RMA number. You will need to provide the product's serial number (if applicable), your return shipping address, and a daytime telephone number.

 

Phone: 1-888-70XY-SURE

E-mail: ***@***

STEP 2: Ship the unit, along with the RMA number, to OxySure®.

 

Once you have received the RMA number, securely package the product and ship it (insured) to the following address:

 

OxySure Systems, Inc.

 

Attn: Customer Service

10880 John W. Elliott Road, Suite 600

Frisco, Texas 75034 USA

 

RMA Number: (insert your RMA number here - see above)

 

 

 

 

 

7.       AS REQUIRED BY THE CONDITIONS OF THE CONTRACT, THERE ARE REPORTED ABOVE ALL GOVERNMENT SALES FOR ITEM(S) UNDER THE CONTRACT IDENTIFIED. THIS REPORT IS ACCURATE TO THE BEST OF OUR KNOWLEDGE AND BELIEF.

 

AUTHORIZED OFFICIAL (Signature and official title)
	Date: ________
Name and Phone Number for questions or clarifications:	Total Sales:_______
	Dollar Amount IFF: ________
	Date of Electronic Payment Submission: ________

 

 

 

 

 

 

CONTRACTOR CHECKLIST	REQUIREMENT	COMMENTS
o COMPLETE o INCOMPLETE	SPECIAL ITEM NUMBER (SIN) CATEGORY(IES)
o COMPLETE o INCOMPLETE	COVER LETTER	Explain in detail why the proposed Tracking Customer or Category of Customer (TC) is an appropriate customer in terms of ensuring the Government price/discount remains representative of market prices and will continue to benefit from positive price changes.
o COMPLETE o INCOMPLETE	COMMERCIAL SALES PRACTICE (CSP) INFO	Submit a spreadsheet that includes the following information:   o SIN# o Item# o Product Description o Commercial List Price o MFC Name o MFC Discount o MFC Net Price o Proposed Government Discount off List Price o Net FSS Price o Awarded Tracking Customer Ratio o Proposed Tracking Customer o % Discount off List Price o TC Net Price o TC Sales (12 months)
o COMPLETE o INCOMPLETE	QUANTITY DISCOUNTS	Identify any proposed additional quantity discounts offered to the Government
o COMPLETE o INCOMPLETE	ADDITIONAL DISCOUNTS	Identify any proposed additional discounts/concessions, including prompt payment discounts, annual rebates, etc. offered to your commercial customers

 

CONTRACTOR CHECKLIST	REQUIREMENT	COMMENTS
o COMPLETE o INCOMPLETE	PRODUCT INFORMATION	Product was added at:   o TIME OF AWARD   o MODIFICATION#           o MODIFICATION EFFECTIVE DATE
o COMPLETE o INCOMPLETE	COMMENTS

 

 

CONTRACTOR NAME
CONTRACT#
ADDRESS1
ADDRESS2
CITY/STATE/ZIP
PHONE
EMAIL
DATE SUBMITTED TO VA-NAC

PO BOX 26, BLDG 37

MS 001AL-A2-2

1 BLOCK N 22ND STREET

HINES, IL 60141

 

Provide the following information for ADMINSTRATIVE/OTHER CHANGE

CONTRACTOR CHECKLIST	REQUIREMENT	COMMENTS
o COMPLETE o INCOMPLETE	SPECIAL ITEM NUMBER (SIN) CATEGORY(IES)
o COMPLETE o INCOMPLETE	REASON FOR MODIFICATION	o Change of Address   o Item Description Change   o Item Code Change   o Add/Delete Contract Administrator   o Warranty Terms   o Shipping Lead Times   o Add/Delete Distributor   o Other
o COMPLETE o INCOMPLETE	DOCUMENTATION	Provide all appropriate documentation related to your request.

 

_______________________________________________	_______________________________________________
AUTHORIZED REPRESENTATIVE	DATE

 

---

 

 

_______________________________________________	_______________________________________________
CONTRACTING OFFICER	DATE

 

_______________________________________________

 

NOTE:  The effective date of the modification will be determined at the time of approval of the request by the Contracting Officer.  Effective dates will be assigned as either the 1st or 15th of the month.