AMS INPUT SHEET - MODIFICATION

PREPARER: Fill in all applicable (except shaded) blocks. Italicized blocks need not be filled in unless there are changes.

Underlined blocks apply to New Work modifications

1. Contract or Order Number / 116. Mod Prefix / ’ / 117. Mod Number
31. Referenced Contract Number / 3. PR Number / 4. Closeout PR
If this is a mod to an IDV order, enter the contract that the order was against, e.g. the FSS number. Otherwise leave blank.
4a. More than one PR (Yes) (No) /
4b. Num of Linked PRs
18. Modification Award Date...... / yyyy/mm/dd / 66. Effective Date (New Work ONLY)
Enter the year, month, and day that the CO signed the modification.
80. Completion Date...... / 81. Ultimate Completion Date......
ENTER ONLY IF CHANGING CURRENT PERIOD OF PERFORMANCE (e.g. by exercise of option) OR DATE OF LAST DELIVERED ITEM, WHICHEVER IS LATER / ENTER ONLY IF CHANGING MAXIMUM POSSIBLE PERIOD OF PERFORMANCE (e.g. by negotiation of a contract delivery extension).
20. PPC (New Work ONLY)...... ……….. / 21. Kind of Action...... …………..
07-Additional Work (new agreement,
FAR Part 6 applies),
08-Supplemental Agreement for
work within scope
_____ Changes clause (Y)es (N)o
09-Change Order,
10-Definitize Change Order,
11-Other Administrative Action
12-Terminate for Default (complete or partial)
13-Terminate for Convenience
(complete or partial), / 14-Definitize Letter Contract,
15-Exercise an Option,
16-Order under Reporting Center’s IDC
17-Order under Reporting Center’s BOA
53 Mod to BOA and no other code applies
54 Mod to Purchase/Task/Delivery Order
and no other code applies
97-Funding Only Action
98-Novation Agreement,
99-Close Out Mod
26. Extent of Competition (New Work ONLY)
Competed
2. Sealed Bid
3. Competed Action – SEB
4. Other Competed Action / Not Competed
5. Follow-on to Competed Action
6. Other Not Competed
28. Solicitation Issue Date / 29. Solicitation Identifier
32. Brief Mod Description
(limit 100 characters)
Examples: / Administrative Change – [summarize what was changed]
Change Order: [Title or CCB reference no.] – [summarize]
Mod definitizing Change Order Mod #___ / New work – [summarize work]
Change in task – [summarize]
Increase POP/Cost/Funding
Award Fee Earned for period ____(dates)
33. CICA Applicability.... / 36. Procurement Synopsized......
1. Pre-CICA 2. Post-CICA
3-Simplified Acquisition Procedures
4-Commercial Item Under Test Program / (Y)es (N)o (U) No, due to urgency
35. Contract Type...... …………....
01. Fixed Price, Firm
02. Fixed Price, Redetermination
03. Fixed Price, Economic
Price Adjustment
04. Fixed Price, Incentive
05. Cost No Fee / 06. Cost Sharing
07. Cost Plus Fixed Fee
08. Cost Plus Incentive Fee
09. Time and Materials
10. Labor-hour
12. Cost Plus Award Fee / 13. Fixed Price Level of Effort
14. Fixed Price Award Fee
15. Order dependent
16. Combination
17. Award Term
18. Other
Contract/Modification Number
40. Number of Offers Received....………………...... / 41. Solicitation Procedures...... …………...……......
E. NASA Research Announcement/
Announcement of Opportunity
L. Other Than Full and Open Competition
(Includes8(a) Program)
42. Authority Other Than full and Open..…………….... / 46. Contract Admin Delegated (Y)es (N)o.……………………
A. Unique Source (1)
B. Follow-on Contract (1)
C. Unsolicited Research Proposal (1)
D. Patent/Data Rights (1)
E. Utilities (1)
F. Standardization (1)
G Only One Source- Other (1) / H. Urgency (2)
J. Mobilization, Essential R&D Capabilities, or Expert Services (3)
L. International Agreement (4)
M. Authorized by Statute (5)
N. Authorized for Resale (5)
P. National Security (6)
Q. Public Interest (7) / If Yes, check either Blanket Delegation OR all that apply
____Blanket Delegation
____Post Award Audit
____Security
____Cost Accounting Standards
____Property Administration / ____Transportation
____Quality Assurance
____Consent to Subcontract
____Closeout
____Engineering/Product Surveil.
____Other
50. Cost Accounting Standards Clause (Y)es (N)o / 52. Subcontracting Program Plan ……………………………..
A. Plan Not Included – No Subcontracting Possibilities
B. Plan Not Required
C. Plan Required – Incentives Not Included
D. Plan Required – Incentive Included
56. Cost and Performance Reporting...... / 57. Property Financial Reporting...... (Y)es (N)o
N. None required 2. NF 533M only 3. NF 553M & 533Q
38. Percent Performance Based...... …………..….. / 82. Physically Complete Y/N ____. If Yes, enter date
69. Mod Admin’s Code / 70. Contracting Officer's Code / 71. Negotiator’s Code
43. Labor Statutes / 67. Security Code / 68. Equipment Code
72. COTR Last Name and First Initial / 73. COTR's Org Code / 74. Contract Funding Code
75. Reason Not Small Business ……………………………… / 55. Contract funded by Foreign Gov¢t/Int¢l Org
A No known sm. bus. source
B SB not solicited
C SB solicited and no offer received / D SB solicited and offer was not low
Z Other reason
90. EPA Designated Products...... ………………… / 91. Recovered Materials Clauses......
A. Purchase Contained Required Minimum Recovered Material Content
B. No Minimum Recovered Material Content; Unable to Competitively
Acquire w/in Reasonable Time
C. No Minimum Recovered Material Content; Unable to Acquire at
Reasonable Price
D. No Minimum Recovered Material content; Unable to Acquired at
Reasonable Performance Standards
E. No EPA Product(s) Required. / A. FAR 52.223-4, Recovered Material Certification,
B. FAR 52.223-4, Recovered Material Certification and
FAR 52.223-9, Estimate of Percentage of Recovered
Material Content for EPA Designated Products.
C. Neither clause stated in B is included in the contract.
95. Funding Agency Code (FIPS 95 code)…………….. / 96. Funding Agency DODAAC Code......
This field may be blank. If reporting an award done by your Center on behalf of another federal agency, and 100% of the funding comes from that other agency, report the four-digit agency code (FIPS 95) of the funding agency. The FIPS 95 code should be placed on the Purchase Request by the finance office. A list of valid codes is available at http://FPDS.GSA.GOV/fpds/downloads.htm. / If the award being reported in Funding Agency (Item 95) is for the Department of Defense (begins with 17, 21, 57, 96CE, or 97) enter the six digit Department of Defense Activity Address Code (DODAAC).
64. Value Engineering Clause.....……......
Contract/Modification Number

111. Revised Fixed Price or Estimated Cost Plus Fees

FROM / BY / TO
Fixed Price or Est. Cost / Fixed Price or Est. Cost / Fixed Price or Est. Cost
$ / $ / $
Base/Fixed Fee / Base/Fixed Fee / Base/Fixed Fee
$ / $ / $
Target Incentive Fee / Target Incentive Fee / Target Incentive Fee
$ / $ / $
Maximum Award Fee / Maximum Award Fee / Maximum Award Fee
$ / $ / $
Total Price or Cost With Fees / Total Cost With Fees / Total Cost With Fees
$ / $ / $

110. Total Contract Value (NOTE: UPDATE TOTAL CONTRACT VALUE INCLUDING ALL OPTIONS, EXERCISED OR FUTURE)

$

Award Fee Modifications

Award fee period - From...... / To......
Max fee available for period.... / $ / Amount Earned for period.... / $
Award Fee Lost...... / $

113. Action Obligations

FROM / BY / TO
Fixed Price or Est. Cost / Fixed Price or Est. Cost / Fixed Price or Est. Cost
$ / $ / $
Total Fees / Total Fees / Total Fees
$ / $ / $
Total Obligated / Total Obligated / Total Obligated
$ / $ / $
114. Funded Through date
Contract/Modification Number
DELIVERABLES (COMPLETE ONLY IF ITEM(S) HAVE BEEN CHANGED OR ADDED) (OPTIONAL)
Description / Due Date / Revised Date / Actual Date / Delay Code *
1.
2.
3.
4.
5.
6.
7
8
9.
10.
11.
12.
*AMS Deliverables Delay Code
Delay
Code Description of Delay
A Testing/Inspection Delays
B Labor Problems
C Subcontractor/Supplier Late
D Contract Priorities/Conflicts
E Plant/Facility Closing
F Theft/Loss
G Unacceptable Items
H Contractor Claim Pending / Delay
Code Description of Delay
I Common Carrier/Transportation
J Untimely Provision of GFP
K Government Direction (e.g. Termination,
Stop Work Order, or Suspension Order)
L Other Government-Caused Delay
M Other Contract/Subcontractor-Caused
Delay
N Act of God

Period of Performance (POP) Option End Dates (Complete only if item(s) have been changed or added)

POP Option End Date (1) / POP Option End Date (2)
POP Option End Date (3) / POP Option End Date (4)

HC (10/1/2003) NF507 Template ***Previous Editions are Obsolete*** 4