Form 1413 Statement and Acknowledgement

OMB Control Number: 9000-0014
Expiration Date: 12/31/2014

STATEMENT AND ACKNOWLEDGMENT

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.

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

6. The prime contract
does,
Overtime Compensation."

c. CITY

d. STATE e. ZIP CODE

does not contain the clause entitled "Contract Work Hours and Safety Standards Act --

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

10a. NAME OF PERSON SIGNING

9. LOCATION

12. DATE SIGNED

11. BY (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 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

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)