Form Dot F 4200 1 2Cg – Fill Out and Use This PDF

ITEM

NO.

(A)

ITEM OR SERVICE (Include Specifications and Special Instructions)

(B)

QTY (C)

UNIT (D)

ITEM 1-NAME, PHONE NUMBER, AND ROUTING SYMBOL of person to contact concerning the request.

ITEM 2-TYPE OF REQUEST

A.Check "New Request" if this is an initial request. B. If this is a change to a pending PR, check box, and enter PR number assigned by procurement office. C. If PR is for modifying an existing order or contract, check box, and enter order or contract number assigned by procurement office.

ITEM 3-ORIGINATING OFFICE DATA. Enter any internal data needed by the office preparing the PR, such as internal PR number, project or task number, etc.

ITEM 7- DATE(S) REQUIRED. Enter the date(s) that items

are required. Do not use "as soon as possible" or similar terms. When the requested items and/or services are required sooner than the normal procurement lead-time would permit, a written justification should be attached to the PR. The justification should state why expedited handling is necessary and the probable results if the indicated delivery date(s) is not met.

ITEM 8-GOVERNMENT FURNISHED PROPERTY. If "Yes" is checked, describe each item to be furnished by the Government and state its acquisition cost (estimated if unattainable), and state the use to be made of the item(s) by the contractor.

ITEM 4-ADDITIONAL INFORMATION. Use this space to

indicate suggested sources of supply, any applicable security classification, or for other instructions or data. If the items or services are proposed to be obtained from only one source of supply, furnish a "sole source" justification with the PR.

ITEM 5-APPROVALS.

COL. A-APPROVING OFFICIALS. Enter typed name and title for approving officials as indicated below:

(1)Authorized Requisitioner. Signature of person authorized to approve request for procurement action.

(2)Accounting Certification Officer. Signature of accounting representative having authority to certify that funds are available for the procurement.

(3)and (4) For use as may be required by local instructions.

COL. B-ROUTING SYMBOL. Self-explanatory.

COL. C-DATE. Give date of approval.

COL. D AND COL. E-INTERNAL ROUTING. Use these blocks only if internal review and intermediate approvals are required by approving officials.

ITEM 6-CONSIGNEE AND DESTINATION. Enter the name of

consignee and address location where requested items are to be delivered or services are to be performed. If shipments are to be made to more than one destination, enter the words "Multiple Destinations" in this block and attach a list of the consignee addresses where shipments are to be made.

ITEM 9-DESCRIPTION OF ITEMS OR SERVICES.

COL. A-ITEM NO. Enter item numbers in numerical sequence.

COL. B-ITEM OR SERVICE. Identify applicable specifications, drawings, and purchase descriptions, and attach a copy of each. Provide Federal Stock Numbers if known and manufacturer's part number, if applicable.

If a brand name or equal product, state the commercial brand name and model, and set forth those characteristics essential to Government needs.

Furnish any special shipping and routing instructions, and any preservation, packaging, packing, and marking instructions.

Furnish any other instructions, such as inspection and testing requirements.

COL. C-QUANTITY. Enter quantity of each item requested.

COL. D-UNIT. The measure, such as "each" or "set".

COL. E-ESTIMATED UNIT COST. Use the most current price available, i.e., the reasonable "going market price," as may be obtainable from commercial catalogs, price lists, bulletins, reports, trade journals and the like. If the requested item or service has been previously procured, and no other more current pricing data is available, use last known purchase price.

COL. F-ESTIMATED TOTAL COST. Enter the total estimated cost for each item, and grand total cost

ITEM 10-ACCOUNTING DATA. Enter the appropriation(s) under which funds have been made available, and any other accounting data required. Reference Finance Center S.O.P. M7000.1.