Form SF-1413 Statement and Acknowledgment

OMB No.: 9000-0014
Expires:
4/30/2008

STATEMENT AND ACKNOWLEDGMENT

Public reporting burden for this collection of information is estimated to average 30 minutes 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 FAR Secretariat, (VIR), Regulatory and Federal Assistance Division, GSA, Washington, DC 20405; and to the Office of
Management and Budget, Paperwork Reduction Project (9000-0014), Washington, DC 20503.

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

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

12. DATE SIGNED

(Signature)

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 Davis-Bacon and Related Act Regulations

Davis-Bacon Act
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

15b. TITLE OF PERSON SIGNING
AUTHORIZED FOR LOCAL REPRODUCTION
PREVIOUS EDITION IS NOT USABLE

STANDARD FORM 1413

(REV. 7/2005)

Prescribed by GSA/FAR (48 CFR) 53.222(e)