State Form 45769 - Certificate Of Printing Contract Performance - 2001

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Name of contracting Vendor / EPIC / DOC

CERTIFICATE OF PRINTING

CONTRACT PERFORMANCE

Purchase Order number / Job number

Request for Printing number

State Form 45769 (R2 / 8-01)

INSTRUCTIONS:

Upon completion of printing job, contracting vendor's representative will inspect products to be shipped and select FOUR

representative samples to be submitted with this Certificate.

After completing and signing this Certificate, samples will be attached and delivered to:

Indiana Commission on Public Records

Forms Management Division

402 W. Washington St., Rm. W472

Indianapolis, IN 46204

(Please check one)

State Form

Non Form

PRODUCT DELIVERED UNDER CONTRACT

DESCRIPTION (as shown in Purchase Order)

QTY. DELIVERED DATE DELIVERED

PLACE DELIVERY MADE

AMOUNT

(Please check one)

Partial Order

Completed Order

CERTIFICATION OF VENDOR

The undersigned, in order to induce prompt payment, hereby certifies, represents and affirms under penalties of perjury, to the Indiana Department of

Administration:

that the attached required samples of the product specified in the above-cited Purchase Order have been inspected and compared to the delivered

portion of the printing job, that they are representative of the entire quantity delivered, and that they are equal in quality to the entire printing job

which has been produced and delivered in accordance with approved contract specifications (except as noted in Item 5 below);

that the contract terms and conditions have been fully performed, that no contract obligation remains unperformed by our firm, and that all approved

contract specifications have been met (except as noted in Item 5 below);

that all artwork or other material either provided by or paid for by the State of Indiana to the vendor in connection with this contract order have been

returned as noted in item 6 below; and

that the individual executing this Certificate affirms that every reasonable effort has been undertaken to verify the information transmitted

here, and that the statements contained are true, accurate and complete to the best knowledge and belief of the undersigned individual.

E x c e p t i o n s :

6. Disposition of artwork / material

Forms returned to

Indiana Commission On Public Records

Non - Forms Returned to "Ship to" Agency

Forms Management Division

402 W. Washington St., Rm. W472

Indianapolis, Indiana 46204

Delivered to _______________________________________

Signature of contracting vendor representative

Printed / typed name

Title of contracting vendor representative

Date signed

RECYCLED PAPER REQUIREMENT

Greening the Government requires printing on paper that contains at least 30% post-consumer recycled fiber, unless it is not available. Was the printing job

printed on recycled paper?

Yes

If Yes, note percentage ___________ % of post-consumer content. If No, explain:

REVIEW OF SAMPLES AND DETERMINATION OF COMPLIANCE BY FORMS MANAGEMENT DIVISION, ICPR

The Forms Management Division of the Indiana Commission on Public Records, or the requesting agency's representative, has

reviewed the samples submitted, compared them with the approved specifications, in the case of forms, and has determined

that they are:

ACCEPTABLE "AS IS"

NOT ACCEPTABLE for the following reason(s):

ACCEPTABLE CONDITIONALLY for the following reason(s):

Printed / typed name

Signature of reviewer