Form Gsa 2957 - Reimbursable Work Authorization - 2011

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REIMBURSABLE WORK AUTHORIZATION
Unless specified otherwise, the authority for this agreement is
40 U.S.C. § 592(b)(2).
(See instructions on Page 4)
1. DATE OF REQUEST
2. RWA NUMBER (GSA Use Only)
3. TYPE OF REQUIREMENTS (GSA Use Only)
SEVERABLE
NON-SEVERABLE
GOODS
4. AGENCY AND BUREAU NAME
5. WORK LOCATION
6A. AGENCY CONTACT NAME
6E. AGENCY CONTACT'S ADDRESS
6B. AGENCY CONTACT'S TELEPHONE NUMBER
EXTENSION
6C. AGENCY CONTACT'S E-MAIL
7. DESCRIPTION OF REQUIREMENTS (attach Statement of Work, as necessary)
6D. AGENCY CONTACT'S FAX NUMBER
9A. BILLING TYPE
9B. BILLING TERMS
8. AMENDMENT
(See Instructions)
(See Instructions)
RWA amendment provided to
change total authorized amount by
$
from $
to $
.
10C. REQUISITION
10A. AGENCY LOCATION CODE
10B. FISCAL
STATION NUMBER
IDENTIFICATION NUMBER
(DOD ONLY)
11. REQUESTED WORK DATES
12. AGENCY CERTIFIED AMOUNT
13B. AGENCY
13A. AGENCY ACCOUNTING DATA (Limited to 130 characters)
FUND YEAR
A. START
B. COMPLETION
14A. AGENCY BILLING CONTACT E-MAIL ADDRESS
13C. FUND TYPE Please check Fund Type. If applicable, also
13D. EXPIRATION
check RECOVERY ACT - see instructions.
DATE OF
OBLIGATIONAL
NO-YEAR
AUTHORITY
14B. AGENCY FINANCE BILLING OFFICE
ANNUAL APPROPRIATION
APPROPRIATION
MULTIPLE YEAR
RECOVERY ACT
APPROPRIATION
14C. STREET ADDRESS
13E. AGENCY/CUSTOMER BUSINESS
13F. AGENCY/CUSTOMER ORDER NUMBER
PARTNER NETWORK/DATA UNIVERSAL
NUMBERING SYSTEM NUMBER (BPN/DUNS)
14D. CITY
14E. STATE
14F. ZIP CODE
13G. TREASURY ACCOUNT SYMBOL
15A. FUNDING AGENCY CODE (FPDS)
15B. FUNDING OFFICE CODE (FPDS)
GENERAL SERVICES ADMINISTRATION INTERNAL CUSTOMER OR INTERFUND CUSTOMER ONLY
16. FED CODE
17. PEGASYS DOCUMENT NUMBER
18. PEGASYS ACCOUNTING LINE NUMBER
19. FUND CODE
20. INTERFUND YEAR
By its signature below, the Requesting Agency certifies (a) that all special funding and procurement requirements of the Requesting Agency, including
statutory or regulatory requirements applicable to the funding being provided by the Requesting Agency, have been disclosed to GSA; (b) that all internal
reviews/approvals required by the Requesting Agency prior to placing this RWA with GSA have been completed; (c) that the Requesting Agency has a bona
fide need in the current fiscal year for the work described in this RWA; (d) that the funds identified by the Requesting Agency in this RWA are legally
available for further obligation and expenditure by GSA in furtherance of the work described in this RWA; and (e) that the Requesting Agency accepts the
General Terms and Conditions set forth on page 3 of this RWA. Further written assurances regarding funding availability may be required depending on the
facts and circumstances of individual requests.
21A. SIGNATURE OF FUND CERTIFYING OFFICIAL
21B. DATE
21C. NAME OF FUND'S CERTIFYING OFFICIAL
21D. CERTIFYING OFFICIAL'S E-MAIL ADDRESS
21E. TELEPHONE NUMBER OF CERTIFYING OFFICIAL
PHONE NUMBER
EXTENSION
NOTE: The General Services Administration will bill in accordance with Federal Management Regulation (41 CFR) Section 102-85.195. It
is anticipated that the Agency Certified Amount provided in Block 12 will be sufficient to complete the work requirements of the Requesting
Agency. If it is determined that the funds provided by the Requesting Agency will be insufficient to complete the work requested under this
agreement, GSA will seek an amended RWA from the Requesting Agency for additional funding prior to incurrence of costs above the
Agency Certified Amount.
GENERAL SERVICES ADMINISTRATION
GSA 2957 (REV. 2/2011)

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