Form GSA Form 1142 GSA Form 1142 Release of Claims

OMB Control Number: 3090-0080
Expiration Date: 6/30/2018

RELEASE OF CLAIMS

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The undersigned contractor, pursuant to the terms of Contract Number
between the United States of America and said contractor for the

located at
hereby release the United States from any and all claims arising under or by virtue of said contract or any
modification or change thereof except as follows: (Here list any claims against the Government and the
amounts thereof. If none, so state.)

Witness the signature and seal of the undersigned this

day of

CONTRACTOR

WITNESS:
(Print or type)

(Signature)

(Signature)

(Address)

(Official Title)

GENERAL SERVICES ADMINISTRATION

(Seal)

GSA 1142 (REV. 5/2015)