Contractor Name:

Contract Number:

Contractor Address:

Contract Value: $

FSC:

Estimated Termination Value: $

CPARS Input Submitted? Yes ☐ No ☐

Order/Modification number

Full or Partial Termination

General Description of Supply or Service:

Reason for Termination:

Additional Relevant Information: (Reference if this is update to previous report.)

Contracting Officer:

Phone Number:

( ) -

Contracting Officer Address:

Email Address:

Activity:

Point of Contact:

Phone Number:

Comm: ( ) -

DSN: -

Point of Contact Address:

Email Address: