Standard Form 1449 - Solicitation/contract/order For Commercial Items - 2012 Page 2
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1
219.
20.
21.
22.
23.
24.
ITEM NO.
SCHEDULE OF SUPPLIES/SERVICES
QUANTITY
UNIT
UNIT PRICE
AMOUNT
32a. QUANTITY IN COLUMN 21 HAS BEEN
RECEIVED
INSPECTED
ACCEPTED, AND CONFORMS TO THE CONTRACT, EXCEPT AS NOTED:
32b. SIGNATURE OF AUTHORIZED GOVERNMENT
32c. DATE
32d. PRINTED NAME AND TITLE OF AUTHORIZED GOVERNMENT
REPRESENTATIVE
REPRESENTATIVE
32e. MAILING ADDRESS OF AUTHORIZED GOVERNMENT REPRESENTATIVE
32f. TELPHONE NUMBER OF AUTHORZED GOVERNMENT REPRESENTATIVE
32g. E-MAIL OF AUTHORIZED GOVERNMENT REPRESENTATIVE
33. SHIP NUMBER
35. AMOUNT VERIFIED
37. CHECK NUMBER
36. PAYMENT
34. VOUCHER NUMBER
CORRECT FOR
COMPLETE
PARTIAL
FINAL
PARTIAL
FINAL
38. S/R ACCOUNT NO.
39. S/R VOUCHER NUMBER
40. PAID BY
42a. RECEIVED BY (Print)
41a. I CERTIFY THIS ACCOUNT IS CORRECT AND PROPER FOR PAYMENT
41b. SIGNATURE AND TITLE OF CERTIFYING OFFICER
41c. DATE
42b. RECEIVED AT (Location)
42c. DATE REC'D (YY/MM/DD)
42d. TOTAL CONTAINERS
STANDARD FORM 1449
BACK
(REV. 2/2012)
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