SECTION A - INDIVIDUAL'S STATEMENT, AND DESCRIPTION OF COMMITMENT CIRCUMSTANCES, AND SUPERVISOR'S REVIEW

(The individual making the unauthorized commitment shall complete items 1 through 5 of Part I, Section A, provide the required documentation, sign, date, and forward to his/her immediate supervisor for completion of Item 6. These documented statements must be signed and dated by both the individual(s) making the unauthorized commitment and the immediate supervisor of the individual(s). Following the immediate supervisor's completion of Part I, Section A, Item 6, and if the supervisor agrees that the commitment should be ratified, the supervisor coordinates with the contracting officer, a review of the ratification documentation file through the individual's chain of command before the information is forwarded to the DISA HCA.

The coordination includes the appropriate head of the individual's cognizant organization or office for completion of Part I, Section B. For DISA personnel, this will be the cognizant organization Deputy Director (DD) or Principal Director (PD). For non-DISA personnel, this will be the appropriate head of that individual's agency or activity. The file shall then be forwarded through the individual's organizational head to the appropriate contracting office, contracting activity, or contracting officer for continued review and processing, as appropriate.)

1.  Statement by individual describing circumstances:

2.  Explain why normal procedures were not followed:

3.  Describe what bona fide Government requirement necessitated the commitment:

4.  Describe the benefits received/derived by the Government, if any. If none, so state. (Give value of benefit, if any, and other pertinent facts.)

5.  List and attach all relevant documents (Include orders, invoices, and other documentary evidence of the transaction(s).):

Include the typed name and title of individual making unauthorized commitment, and

Signature______________________________ Date:____________________________

6.  Comments of immediate supervisor of individual making unauthorized commitment. (The supervisor will complete this information, sign and date it, and if the supervisor agrees that the commitment should be ratified, the supervisor includes the supervisor's endorsement verifying the accuracy and completeness of the documentation; describes the measures taken to prevent a recurrence of unauthorized commitments; and provides a purchase description and funding for the ratification action.):

Include the typed name, title, and organization of the supervisor, and

Signature______________________________ Date:____________________________