Form 0896a Report of Subcontracts to Small and Veteran-Owned Busine

OMB Approved No. 2900-0741
Respondents Burden: 2 Hours
Expiration Date: Sept. 30, 2019

REPORT OF SUBCONTRACTS TO SMALL AND VETERAN-OWNED BUSINESS
PAPERWORK REDUCTION ACT NOTICE: The Department of Veterans Affairs (VA), Office of Small and Disadvantaged Business Utilization (OSDBU) is required to collect details on subcontracts awarded to ServiceDisabled Veteran-Owned Small Business and Veteran-Owned Small Business in accordance with Public Law (P.L.) 109-461(a)(4). This form is required annually for VA's large prime contractors with Commercial and Individual
Subcontracting Plans and includes the collection of information on all small business subcontractors.
The collection of information meets the requirement of 38 USC 8127(a)(4). We estimate the time to fill out the form to be about 2 hours. VA cannot conduct or sponsor a collection of information unless a valid OMB control number
is displayed. You are not required to respond to a collection of information if this number is not displayed. Your obligation to respond to this form is mandatory.
If additional reporting space is needed in section 9., please attach a second form.
This form is to be submitted at the same time the prime contractor reports annual subcontracting achievements in the Electronic Subcontract Reporting System (eSRS), www.esrs.gov, see FAR 19.704(a)(10)(iii) and
19.704 (d)(4). The form must be emailed to each VA Contracting Officer listed in Item 9.O., of this form with a copy to VA OSDBU at [email protected]. It is the responsibility of the prime contractor to ensure the correct email
address is utilized.
PRIME CONTRACTORS' INFORMATION
1. NAME AND ADDRESS OF PRIME CONTRACTOR
(Provide street, city, state, and ZIP code)

2. OFFICE TELEPHONE NO.

3. E-MAIL ADDRESS

4. INDIVIDUAL RESPONSIBLE FOR SUBCONTRACT ADMINISTRATION

5. PRIME CONTRACTOR'S DUNS NO.

6. NAME AND TITLE OF PERSON CERTIFYING INFORMATION

7. SIGNATURE OF CERTIFYING OFFICIAL

8. TYPE OF SUBCONTRACTING PLAN(S)
NAME OF AGENCY HOLDING
COMMERCIAL
PLAN (Specify, if not VA)

INDIVIDUAL
(Number of Individual Plans)
9.

A. VA CONTRACT
NUMBER

VA FORM
OCT 2016

B. SUBCONTRACTOR
NAME

0896A

C. SUBD. DESCRIPTION
CONTRACTOR
OF WORK SUBCONTRACTED
DUNS NUMBER

E. NAICS
CODE

F.
SDVOSB

H.
I.
J.
K.
G.
VOSB SDB HUBZone WOSB SB

L.
VERIFIED
IN VIP

M. AWARD
DATE

N. DOLLAR
AMOUNT OF
SUBCONTRACT

O. NAME OF
CONTRACTING
OFFICER

INSTRUCTIONS
This form is required annually for VA's large prime contractors with Commercial and Individual Subcontracting Plans.
Item 1 Provide Name and Address of Prime Contractor.
Item 2 Provide Office Telephone Number for the Prime Contractor's Subcontract Administrator.
Item 3 Provide E-mail Address of Prime Contractor's Subcontract Administrator.
Item 4 Provide Name of Individual responsible for Subcontract Administration.
Item 5 Provide Prime Contractor's DUNS Number.
Item 6 Provide Name and Title of Person Certifying Information on Behalf of the Prime Contractor.
Item 7 Provide Signature of Certifying Official.
Item 8 Select Type of Subcontracting Plan(s). If Commercial Plan, Provide name of Federal Agency Responsible for Plan Approval. If Individual Plan,
Provide Number of Plans with VA for the Fiscal Year Period.
Item 9A Provide VA Contract Number.
Item 9B Provide Subcontractor Name.
Item 9C Provide Subcontractor's DUNS Number.
Item 9D Provide Brief Description of Work Subcontracted (example: consulting services, accounting services, electrical wiring).
Item 9E Provide NAICS Code Utilized for the Subcontract/Determining Size Status of Subcontractor
Item 9F-K Check socio-economic status for the Subcontractor as appropriate; check all that apply. SDVOSB-Service-Disabled Veteran-Owned Small
Business; VOSB-Veteran-Owned Small Business; SDB- Small Disadvantaged Business; HUBZone-Historically Underutilized Business;
WOSB-Woman-Owned Small Business; SB- Small Business
Item 9L Indicate Yes or No if Subcontractor was Verified as denoted in VA OSDBU's Vendor Information Pages ( https://www.vip.vetbiz.gov/ ) at time
of
subcontract award.
Item 9M Provide Subcontract Award Date.
Item 9N Provide Dollar Amount of Subcontract.
Item 9O Provide Name of VA Contracting Officer for the Prime Contract.