Form 700-03 - Contractor'S Release - U.s. Department Of Homeland Security
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112-04-03
U.S. DEPARTMENT OF HOMELAND SECURITY
OMB Control No. 1600-0002
CONTRACTOR’S RELEASE
OMB STATEMENT: This collection of information is mandatory and will be used to fulfill the requirements of the Homeland Security Acquisition
Regulation (HSAR). Public reporting burden is estimated to average 1 hour per response, including the time for reviewing instructions, searching
existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments
regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the FAR
Secretariat (VRS), Office of Federal Acquisition and Regulatory Policy, GSA, Washington, D.C. 20405; and to the Office of Management and
Budget, Information and Regulatory Offices, 7251 7th Street, NW, Washington, DC 20503. Please note that an agency may not conduct or
sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB
control number for this collection is 1600-XX.X
CONTRACTOR (Name and Address)
ENTER SUM OF TOTAL OF AMOUNTS
PAID AND PAYABLE
CONTRACT NO.
$
Pursuant to the terms of the above numbered contract and in consideration of the sum stated above, which has been paid or is to be
paid to the Contractor, or its assignees, the Contractor, upon payment of the said sum by the UNITED STATES OF AMERICA
(hereinafter called the Government), does remise, release, and discharge the Government, its officers, agents, and employees, of
and from all liabilities, obligations, claims, and demands whatsoever under or arising from the said contract, except:
1. Specified claims in stated amounts or in estimated amounts where the amounts are not susceptible of exact statement by the
Contractor, as follows: (or state "None")
2. Claims, together with reasonable expenses incidental thereto, based upon the liabilities of the Contractor to third parties arising
out of the performance of this contract, which are not known to the Contractor on the date of the execution of this release and of
which the Contractor gives notice in writing to the Contracting Officer within the period specified in the said contract; and
3. Claims for reimbursement of costs (other than expenses of the Contractor by reason of his indemnification of the Government
against patent liability) including reasonable expenses incidental thereto, incurred by the Contractor under any provisions of the
said contract relating to patents.
The Contractor agrees, in connection with patent matters and with claims which are not released as set forth above, that it will
comply with all provisions of the said contract, including without limitation those provisions relating to notification to the Contracting
Officer and relating to the defense or prosecution of litigation.
IN WITNESSES WHEREOF, this release has been executed this _______ day of _________________________ 20______.
____________________________________________
(Contractor)
____________________________________________
BY
__________________________________________
____________________________________________
TITLE __________________________________________
NOTE: In the case of a corporation, witnesses are not required but the statement below must be completed.
I, ____________________________________________, am the _____________________________________secretary of
the corporation named as Contractor in the foregoing release; that _____________________________________who signed
said release on behalf of the Contractor was then _____________________________of said corporation; release was duly
signed for and in behalf of said corporation by authority of its governing body and is within the scope of its corporate powers.
(CORPORATE SEAL)
____________________________________
(Signature)
DHS Form 0700-03 (07/03)
Authorized for Local Reproduction
53-5
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