Statement and Acknowledgement Form (Subcontracting)

OMB Control Number: 9000-0014
Expiration Date: 1/31/2021
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 9000-0014. We estimate that it will take .05 hours to read the instructions, gather the facts, and answer the questions. Send only comments relating to our time 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 F Street, NW, Washington, DC 20405.

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)