GSA Form 1142 Release of Claims

General Services Administration Acquisition Regulation (GSAR); Contract Financing Final Payment; 552.232-72, (GSA Form 1142 Release of Claims)

GSA1142-15a

OMB: 3090-0080

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

RELEASE OF CLAIMS

Paperwork Reduction Act Statement - This information collection meets the requirements of 44 U.S.C. § 3507, as amended by section 2
of the Paperwork Reduction Act of 1995. You do not need to answer these questions unless we display a valid Office of Management
and Budget (OMB) control number. The OMB control number for this collection is 3090-0080. We estimate that it will take 6 minutes to
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Regulatory Secretariat Division (M1V1CB), 1800 F Street, NW, Washington, DC 20405.

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)


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