DD-1419 DoD Industrial Plant Equipment Req

REQUISITION NUMBER

DOD INDUSTRIAL PLANT EQUIPMENT REQUISITION

Form Approved
OMB No. 0704-0246
Expires Feb 28, 2006

The public reporting burden for this collection of information is estimated to average 1.5 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 aspect of this collection
of information, including suggestions for reducing the burden, to Department of Defense, Washington Headquarters Services, Directorate for Information Operations and Reports (0704-0246),
1215 Jefferson Davis Highway, Suite 1204, Arlington, VA 22202-4302. Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any
penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number.

PLEASE DO NOT RETURN YOUR FORM TO THIS ADDRESS. RETURN COMPLETED FORM TO
DEFENSE SUPPLY CENTER RICHMOND, ATTN: JH, 8000 JEFFERSON DAVIS HIGHWAY, RICHMOND, VA 28297-5100
SECTION I - ITEM DESCRIPTION

1. COMMODITY CODE

2. MANUFACTURER

4. STOCK NUMBER

5. POWER CODE

3. MODEL NUMBER

7. PHYSICAL INSPECTION
REQUIRED (X one)

6. ESTIMATED COST

YES

8. PROCUREMENT SPECIFICATION
ATTACHED (X one)

NO

YES

NO

YES

NO

9. DESCRIPTION

CONTINUED UNDER REMARKS SECTION

SECTION II - ROUTING AGENCY/FACILITY/CONTRACTOR
10. NAME AND ADDRESS (Include ZIP Code)

12. DATE (YYYYMMDD)

13. COMMAND CODE

17. DATE CERT. N/A
REQUIRED
(YYYYMMDD)

18. PRIORITY

11. CONTRACT NUMBER

14. PROGRAM (X one)
MILITARY

CONTRACTOR

15. INTENDED USE

16. DATE ITEM REQUIRED AT
DESTINATION (YYYYMMDD)

19. BASIS FOR AUTHORIZATION (X one)

20. PROCUREMENT PLANNED (X one)

PRODUCTION

21. REBUILD/OVERHAUL
CANDIDATE

MOBILIZATION
NO (If "YES," cite Appropriation)

YES

REPLACEMENT
22. TYPED NAME AND TITLE OF REQUESTING OFFICIAL

25. CERTIFICATION OF NEED BY ADMINISTERING ACTIVITY
b. NAME AND ADDRESS (Include ZIP Code)

YES
24. DATE (YYYYMMDD)

23. SIGNATURE OF REQUESTING OFFICIAL

a. ADMINISTERING OFFICE CODE
c. TYPED NAME AND SIGNATURE OF PRODUCTION
REPRESENTATIVE

d. DATE (YYYYMMDD)

e. SIGNATURE OF ADMIN. CONTRACTING OFFICER

f. DATE (YYYYMMDD)

SECTION III - APPROVAL AUTHORITY
26. NAME AND ADDRESS (Include ZIP Code)

27. TITLE, SYMBOL AND TELEPHONE NO. OF APPROVING OFFICIAL

29. DATE (YYYYMMDD)

28. TYPED NAME & SIGNATURE OF APPROVING OFFICIAL

SECTION IV - ALLOCATION AND AUTHORITY TO INSPECT (To be completed by DSCR)
30. COMMODITY CODE

31. I.D./GOVERNMENT TAG NUMBER

33. PRESENT LOCATION (Name, address and ZIP Code)

32. DESCRIPTION (See attached copy of DD Form 1342, dated)

34. SHIPPED TO (Name, address and ZIP Code)

35. ESTIMATED TIME REQUIRED FOR SHIPMENT FROM DATE OF ACCEPTANCE (Enter number of days)
a. AS IS CONDITION

b. TEST REQUIRED

36. TYPED NAME AND SIGNATURE OF ALLOCATING OFFICIAL

c. REPAIR REQUIRED

d. REPAIR/OVERHAUL REQUIRED

37. DATE (YYYYMMDD)

e. STANDARD ATTACHMENTS REQUIRED

38. DATE OFFER EXPIRES (YYYYMMDD)

SECTION V - NON-AVAILABILITY CERTIFICATE (To be completed by DSCR)
39. The item described in Section I of this form has been screened by DSCR against the idle inventory of the Department of Defense and it is hereby certified as

not available or cannot be delivered on or before the date specified in Section II (Item 16). Procurement action resulting from this Certification of NonAvailability must be initiated within 45 calendar days of the date included in this Section (Item 42) or complete rescreening is required. Equipment offered by
DSCR in Section IV must be considered if the supplier cannot deliver new equipment before expiration of the period specified in Section IV (Item 35).

40. TYPED NAME AND SIGNATURE OF CERTIFYING OFFICIAL

DD FORM 1419, JUN 2003

41. DATE CERTIFICATE
ISSUED (YYYYMMDD)

42. DATE CERTIFICATE
EXPIRES (YYYYMMDD)

PREVIOUS EDITION IS OBSOLETE.

43. CERTIFICATE NUMBER

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SECTION VI - CERTIFICATE OF ACCEPTANCE
44. THE ITEM ALLOCATED IN SECTION IV OF THIS FORM (X as applicable)
a. HAS BEEN PHYSICALLY INSPECTED AND IS ACCEPTABLE

b. IS ACCEPTABLE WITHOUT PHYSICAL INSPECTION

c. IS ACCEPTED UNDER ONE OF THESE CONDITIONS:
(1) AS IS CONDITION

(2) REPAIR REQUIRED

(3) TEST REQUIRED

(4) REBUILD/OVERHAUL REQUIRED

(5) OTHER
d. IS NOT ACCEPTABLE (A complete description of conditions making item unacceptable must be stated under REMARKS below)
45. TYPED NAME AND TITLE OF CERTIFYING OFFICIAL

46. SIGNATURE OF CERTIFYING OFFICIAL

47. DATE (YYYYMMDD)

SECTION VII - SPECIAL SHIPPING INSTRUCTIONS
48. SHIP TO (Include ZIP Code)

49. FOR TRANSSHIPMENT TO (Include ZIP Code)

50. MARK FOR

d. PAYING OFFICE/ACTIVITY NAME AND ADDRESS (Include ZIP Code)

51. APPROPRIATION CHARGEABLE FOR
a. PACKING/CRATING/HANDLING

b. TRANSPORTATION

c. OTHER
52. SPECIAL DISTRIBUTION OF SHIPPING DOCUMENTS AND OTHER INSTRUCTIONS

SECTION VIII - REMARKS
53. REMARKS

DD FORM 1419 (BACK), JUN 2003

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