Attachment 5.b - RMWT LEO GEPs Model Task Order 01

FA240126R0003 ATTACHMENT 5

PAGE 1 OF

ORDER FOR SUPPLIES OR SERVICES

1. CONTRACT/PURCH ORDER/AGREEMENT NO.
TBD

2. DELIVERY ORDER/CALL NO.
TBD

6. ISSUED BY

CODE FA2401

FA2401 SPACE DEVELOPMENT AGENCY SDA

MEADOWS 1 CP 571 372 5007, 4755 MEADOW WOOD LANE

CHANTILLY, VA 20151-2222

3. DATE OF ORDER/CALL

(YYYYMMMDD)

7. ADMINISTERED BY (If other than 6)

CODE

8. DELIVERY

FOB

DESTINATION

OTHER

SCD: C PAS:

(See
Schedule if
other)

CODE TBD

9. CONTRACTOR

FACILITY

10. DELIVER TO FOB POINT

BY (Date)

(YYYYMMMDD)

TBD

NAME

AND

ADDRESS

4. REQUISITION/PURCH REQUEST NO. 5. PRIORITY

11. X IF BUSINESS IS

SMALL

SMALL

DISADVANTAGED

See Schedule

WOMEN-OWNED

12. DISCOUNT TERMS

Net Days 30

13. MAIL INVOICES TO THE ADDRESS IN BLOCK

14. SHIP TO

See Schedule

CODE

15. PAYMENT WILL BE MADE BY

CODE

MARK ALL

PACKAGES

AND

PAPERS WITH

IDENTIFICATION

NUMBERS IN

BLOCKS 1 AND

2.

16. TYPE OF

ORDER

DELIVERY/

CALL

This delivery order/call is issued on another Government agency or in accordance with and subject to terms and conditions of above numbered contract.

PURCHASE

Reference your
furnish the following on terms specified herein.
ACCEPTANCE. THE CONTRACTOR HEREBY ACCEPTS THE OFFER REPRESENTED BY THE NUMBERED PURCHASE ORDER AS IT MAY PREVIOUSLY HAVE BEEN OR IS NOW MODIFIED, SUBJECT TO ALL OF THE TERMS AND CONDITIONS SET FORTH, AND AGREES TO PERFORM THE SAME.

NAME OF CONTRACTOR

SIGNATURE

TYPED NAME AND TITLE

DATE SIGNED

(YYYYMMMDD)

If this box is marked, supplier must sign Acceptance and return the following number of copies: 1

17. ACCOUNTING AND APPROPRIATION DATA/LOCAL USE

See Section G - Contract Administration Data
18. ITEM NO.

20. QUANTITY

ORDERED/

ACCEPTED*

19. SCHEDULE OF SUPPLIES/SERVICES

21. UNIT

22. UNIT PRICE

23. AMOUNT

See Schedule
* If quantity accepted by the Government is
same as quantity ordered, indicate by X.
If different, enter actual quantity accepted below
quantity ordered and encircle.

24. UNITED STATES OF AMERICA

25. TOTAL

USD 1.00

26.

CONTRACTING/ORDERING OFFICER DIFFERENCES

BY:

27a. QUANTITY IN COLUMN 20 HAS BEEN

INSPECTED

RECEIVED

ACCEPTED, AND CONFORMS TO

THE CONTRACT EXCEPT AS NOTED:

b. SIGNATURE OF AUTHORIZED GOVERNMENT REPRESENTATIVE

c. DATE

(YYYYMMMDD)

d. PRINTED NAME AND TITLE OF AUTHORIZED GOVERNMENT

REPRESENTATIVE

e. MAILING ADDRESS OF AUTHORIZED GOVERNMENT REPRESENTATIVE

28. SHIP. NO.

29. D.O. VOUCHER NO.

30. INITIALS

32. PAID BY

33. AMOUNT VERIFIED CORRECT

FOR

f. TELEPHONE NUMBER

g. E-MAIL ADDRESS

PARTIAL

FINAL

31. PAYMENT

36. I CERTIFY THIS ACCOUNT IS CORRECT AND PROPER FOR PAYMENT.

a. DATE

34. CHECK NUMBER

COMPLETE

b. SIGNATURE AND TITLE OF CERTIFYING OFFICER