Form SF 1413 SF 1413 Statement and Acknowledgement

OMB Control Number: 9000-0014
Expiration Date: 1/31/2021
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STATEMENT AND ACKNOWLEDGMENT

PART I - STATEMENT OF PRIME CONTRACTOR
2. DATE SUBCONTRACT
AWARDED

1. PRIME CONTRACT NUMBER

3. SUBCONTRACT NUMBER

4. PRIME CONTRACTOR

5. SUBCONTRACTOR

a. NAME

a. NAME

b. STREET ADDRESS

b. STREET ADDRESS

c. CITY

6. The prime contract
does,
Overtime Compensation."

d. STATE e. ZIP CODE

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

11. BY (Signature)

12. DATE SIGNED

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:
Construction Wage Rate Requirements
Contract Work Hours and Safety Standards Act - Overtime Compensation
Apprentices and Trainees
(If included in prime contract see Block 6)
Compliance with Copeland Act Requirements
Payrolls and Basic Records
Subcontracts (Labor Standards)
Withholding of Funds
Contract Termination - Debarment
Disputes Concerning Labor Standards
Certification of Eligibility
Compliance with Construction Wage Rate Requirements
and Related Regulations
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)