Hhs Oig Contractor Self-Disclosure Form - U.s. Department Of Health And Human Services Page 2
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4
5C.6. End Users:
Check box if additional information on page 5, Section H.
C.7. Contracting Officer’s
Name:
Last
First
MI
C.8. Contracting Office
Address:
City
State
ZIP
C.8.1. Contracting Officer’s
ext.
Telephone Number:
C.9. Contract Performance
Location:
City
State
ZIP
C.10. Name of Contracting
Officer’s Technical
Last
First
MI
Representative (COTR)
C.11. COTR’s Telephone
ext.
Number:
C.12. All Federal Agencies
Currently Doing Business With:
D. OTHER AFFECTED CONTRACT (if any)
D.1. Number:
D.2. Short Title:
D.3. Contract Type:
D.4. Contract Value:
$
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