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

DEPARTMENT OF HOMELAND SECURITY

CUMULATIVE CLAIM AND RECONCILIATION STATEMENT

OMB Control No:1600-0002
Expiration Date 01/31/2015

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, Acquisitions 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 01/31/2015.
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.

Subcontract Cost

$

g.

Total Costs (5a through 5f)

$

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:
a.
b.
c.
d.

Total Amount Claimed

$

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

$

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