Draft B2 08.3 SF1413

OMB Control Number: 9000-0066
Expiration Date: 5/31/2027

Statement And Acknowledgment
Part I - Statement Of Prime Contractor

1. Prime Contract Number 2. Date Subcontract 3. Subcontract Number Awarded

4. Prime Contractor

a. Name

5. Subcontractor

a. Name

b. Street Address

b. Street Address

c. City

d. State e. ZIP Code c. City

d. State e. ZIP Code

6. The prime contract

does,
does not contain the clause entitled "Contract Work Hours and Safety Standards Act -- Overtime Compensation."

a. Name Of Awarding Firm

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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:

D

8. Project

R

b. Description Of Work By Subcontractor

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 (If included in prime contract see Block 6) Apprentices and Trainees Payrolls and Basic Records
Compliance with Copeland Act
Withholding of Funds
Requirements
Disputes Concerning Labor Standards
Subcontracts (Labor Standards)
Compliance with Construction Wage Rate Requirements
Contract Termination - Debarment
and Related Regulations
Certification of Eligibility
Authorized For Local Reproduction
Previous Edition Is Not Usable

STANDARD FORM 1413 (REV. 10/2023)

Prescribed by GSA/FAR (48 CFR) 53.222(e)

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

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estimate, including suggestions for reducing this burden, or any other aspects of this collection of information to: U.S. General Services Administration, Regulatory Secretariat Division (M1V1CB), 1800