STATEMENT AND ACKNOWLEDGMENT

OMB No.: 9000-0014

Expires: 01/31/2008

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PART I - STATEMENT OF PRIME CONTRACTOR

1. PRIME CONTRACT NO.

2.DATE SUBCONTRACT AWARDED

3. SUBCONTRACT NUMBER

4. PRIME CONTRACTOR

5. SUBCONTRACTOR

a. NAME

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."

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

9. LOCATION

10a. NAME OF PERSON SIGNING

11. BY (Signature)

12. DATE SIGNED

10b. TITLE OF PERSON SIGNING

PART II – ACKNOWLEDGEMENT OF SUBCONTRACTOR

13. The subcontractor acknowledges that the following clauses of the contract shown in Item 1 are included in this subcontract:

Contract Work Hours and Safety
 Standards Act – Overtime
 Compensation - (If included in prime contract see Block 6)
Payrolls and Basic Records
Withholding of Funds
Disputes Concerning Labor Standards
Compliance with Davis-Bacon and Related Act Regulations

Davis-Bacon Act
Apprentices and Trainees
Compliance with Copeland Act Requirements
Subcontracts (Labor Standards)
Contract Termination – Debarment
Certification of Eligibility

14. NAME(S) OF ANY INTERMEDIATE SUBCONTRACTORS, IF ANY

A

A

B

B

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. 7/2005)

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