Form DHS 700-1 DHS 700-1 Cumulative Claim and Reconciliation Statement

DEPARTMENT OF HOMELAND SECURITY

OMB Control No:1600-0002
Expiration Date 12/31/2007

CUMULATIVE CLAIM AND RECONCILIATION STATEMENT
PRA Burden Statement: This collection of information is mandatory and will be used to fulfill the requirements of the
Homeland Security Acquisition Regulation (HSAR). Public reporting burden is estimated to average 1 hour 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
aspect of this collection of information, including suggestions for reducing this burden, to the Office of the Chief
Procurement Officer, Acquistions Policy and Legislation, Department of Homeland Security, Washington, DC 20528.
Please note that an agency may not conduct or sponsor, and a person is not required to respond to, a collection of
information unless it displays a currently valid OMB control number. The OMB control number for this collection is
1600-0002 and it expires 12/31/07.
1. Name of Contractor
2. Address of Contractor

3. Contract No.

4. Delivery/Task Order No.

5. The total amount claimed under the above numbered contract, delivery order, or task order is as follows:
a. Direct Labor
$
b. Direct Material
$
c. Other Direct Costs
$
d. Overhead
$
e. G&A
$
f.

g.

Subcontract Cost
Total Costs (5a through 5 F)

a.

Total Amount Claimed

b.

Total Amount Paid by the Government under
Voucher Nos.
Thru
Total Amount (if any) Withheld, Disallowed, etc.
(as explained on the attached sheet)

$
$
h. Fixed Fee
$
i.
Other Fee
$
j.
Total Amount Claimed
$
6. Total amount due under the above numbered contract, delivery order, task order is as follows:

c.
d.

$
$
$

Total Amount Due

I,

$

, as the
(Full Name)

(Title)

of the above named contractor, declare that the above statements are correct in accordance with the records
of the contractor.

(Signature)

DHS Form 700-1 (12/07)

Authorized for Local Reproduction