Gsa 2957 Form – Fill Out and Use This PDF

REIMBURSABLE WORK AUTHORIZATION

Unless specified otherwise, the authority for this agreement is

(See instructions on Page 4)

40 U.S.C. § 592(b)(2).

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

8. AMENDMENT

9A. BILLING TYPE

9B. BILLING TERMS

(See Instructions)

(See Instructions)

RWA amendment provided to

change total authorized amount by

$

from $

to $

.

10A. AGENCY LOCATION CODE

10B. FISCAL

10C. REQUISITION

STATION NUMBER

IDENTIFICATION NUMBER

(DOD ONLY)

11. REQUESTED WORK DATES

12. AGENCY CERTIFIED AMOUNT

13A. AGENCY ACCOUNTING DATA (Limited to 130 characters)

13B. AGENCY

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

NO-YEAR

OBLIGATIONAL

ANNUAL APPROPRIATION

AUTHORITY

14B. AGENCY FINANCE BILLING OFFICE

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

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.

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)

RWA NUMBER (GSA Use Only)

FOR GENERAL SERVICES ADMINISTRATION USE ONLY

	22. PROJECT CONTROL	23A. SUMMARY ORGANIZATION		23B. LEASE NUMBER	23C. BUDGET ACTIVITY				23D. WORK ITEM NUMBER
	NUMBER	CODE				(Check One)
					PG53	PG61		PG80
23E. CUSTOMER BILLING OFFICE ADDRESS CODE (BOAC)			23F. CORRESPONDENCE SYMBOL				23G. AGENCY BUREAU CODE

24A. AGREED-UPON	24B. ESTIMATED		25. BRIEF PROJECT DESCRIPTION (limited to 25 characters)
INITIAL CONTRACT AWARD	COMPLETION DATE
DATE
26. ACTION (Check one)					27. PLEASE CHECK IF APPROPRIATE
NEW				HEATING OPERATIONS AND TRANSMISSION DISTRICT
				(HOTD) - NCR Only
CANCELLED				OVERTIME UTILITIES
CHANGE				PLANS ATTACHED
COMPLETE				SUPPLEMENTAL LEASE AGREEMENT
28A. ORGANIZATION			28B. BUILDING		28C. FUNCTION	28D. OBJECT	28E. TOTAL
CODE			NUMBER		CODE	CLASS

29A. GSA PROJECT CONTACT NAME

32A. CERTIFICATE OF COMPLETION SIGNATURE

GSA 2957 (REV. 2/2011) PAGE 2

GENERAL TERMS AND CONDITIONS

1.The Requesting Agency (RA) will establish the existence of a bona fide need to be satisfied through this Reimbursable Work Authorization (RWA), and otherwise satisfy all internal requirements of the RA regarding documentation of the requirement.

2.The RA will determine and document the need to seek GSA's assistance in performing the work described in this RWA (the Work). Upon request, the RA will provide GSA with copies of such documentation.

3.The RA will provide GSA with such requirements/Statement of Work (SOW), budget/accounting information, points of contact, and other information necessary for GSA to perform the Work.

4.GSA and the RA will work in close cooperation and collaboration throughout the project lifecycle.

5.GSA and the RA agree that the Work will be performed in full compliance with the Competition in Contracting Act and other applicable laws and regulations. In furtherance of so doing:

a)GSA will assist the RA in further defining its requirements in a manner that will aid in GSA's timely performance of the Work;

b)GSA will perform acquisition planning related to any procurement actions to be undertaken in connection with the Work, including, as appropriate,

i)developing and implementing an acquisition strategy responsive to the RA's requirements;

ii)conducting market research;

iii)developing performance-based solicitation requirements when project requirements allow; and

iv)considering all appropriate acquisition vehicles and procurement methods to maximize competition and best value.

c)GSA will comply with requirements of the Federal Acquisition Regulation (FAR), the General Services Administration Acquisition Manual (GSAM), and special acquisition requirements of the RA identified, in writing, to GSA.

6.GSA will administer contracts and resolve contractual issues or disputes arising out of GSA's performance of the Work, including:

a)enforcing contractual terms and conditions to facilitate the timely delivery of goods and services;

b)maintaining contract documentation from project initiation through contract closeout;

c)performing contract oversight, including inspection and acceptance of the Work, in accordance with the terms of the contract;

d)tracking and reporting on the contractor's performance of the Work; and

e)performing contract close-out functions.

7.The RA will not, except as expressly authorized, in writing, by the GSA Contracting Officer, provide instruction or authorization to any GSA contractor regarding performance of the Work.

8.GSA will provide legal support and representation for contract disputes, claims and bid protests arising out of GSA's performance of the Work. The RA will be responsible for all costs associated with termination, disputes, and protests, including settlement costs, except that the RA will not be responsible for costs associated with actions stemming from errors by GSA in performing its responsibilities under this RWA. GSA will consult with the RA before agreeing to a settlement for which RWA funding will be used.

9.The RA will provide cooperation and support to GSA, as required, for GSA to fulfill its contracting responsibilities and otherwise, as necessary, for GSA to perform the Work.

10.The RA will provide funding to cover GSA's direct and indirect costs of performing the Work, including costs associated with RA changes to the Work or increases in cost not attributable to GSA errors in performing its responsibilities under this RWA.

11.GSA will provide an Independent Government Estimate to the RA for the work to be performed or concur with the estimate prepared by the RA. In no event will GSA be required to commence performance of the Work until the RA has provided GSA with funding in an amount sufficient to cover the expected costs of performance.

12.GSA will be a good steward of the RA's funds and provide the RA with periodic updates regarding GSA's further obligation and expenditure of RWA funding. Upon contract completion and close-out of all contracts associated with this RWA, GSA will return to the RA any unused funding.

13.GSA will provide the RA with billing statements and otherwise respond to RA inquiries regarding GSA expenditure of RWA funding.

14.GSA and the RA will advise each other of issues, concerns, or problems related to performance of the Work.

15.This RWA is effective as of the latest date of signature of GSA and the RA, and will remain in effect until completion of the Work or earlier termination in accordance with this paragraph. Any amendments to this RWA, including these General Terms and Conditions, must be in writing and signed by both the RA and GSA. This RWA may be terminated by the RA upon 60 calendar days prior written notice to GSA; provided, that the RA will remain responsible to GSA for any and all direct and indirect costs incurred by GSA in connection with performance of the Work up to the date of termination of the RWA, together with such costs related to termination of contracts entered into by GSA in connection with the Work. Should GSA seek to terminate this RWA, it will do so only with the written agreement of the RA, including costs attributable to each party arising out of any such termination.

16.GSA and the RA agree to use their best efforts to resolve disputes cooperatively at the working levels of their respective organizations regarding the interpretation of this RWA and the roles and responsibilities of the parties hereunder, and, if necessary, to escalate such disputes within their respective organizations. Disputes regarding funding that remain unresolved for more than 90 calendar days will be referred to the respective agency Chief Financial Officers for resolution."

17.If special terms and conditions related to this RWA apply, please include them below or provide as an attachment to this form. Additionally, please annotate in the Description of Requirements (Block 7) that special terms and conditions are provided here on page 3 or as an attachment. If n/a, leave blank or specify "none."

GSA 2957 (REV. 2/2011) PAGE 3

INSTRUCTIONS

GENERAL: Keep a copy for your records and forward one copy to your obligating/paying office.

	ITEM	SPECIFIC ITEM
	NUMBER

1.Enter date of Work request.

2.For GSA Use Only. Enter RWA Number.

3.For GSA Use Only. Check whether the RWA is for severable services, non-severable services, or goods. Goods should only be incidental to a larger PBS project.

4.Enter name of agency requesting the Work. If applicable, enter the specific Agency Bureau name. For example, if an Internal Revenue Service customer, enter "Department of the Treasury, Internal Revenue Service."

5.Enter location where the Work is to be performed.

6A-E. Enter the information regarding the agency's representative responsible for the project, including name, address, telephone and fax numbers, and e-mail address. The agency's representative must have authority to make decisions regarding the project.

7.Provide a summary of the SOW created as a result of requirements development interview(s). The full SOW also should be attached to this form. At a minimum, the Description of Requirements block should include the following components: Location, Type of Work, and Description of Work. For example: Location: Building A, Floor 2; Type of Work: Renovation; Description of Work: Build-out of space to accommodate 50 employees. The Description of Requirements must demonstrate a bona fide need. The bona fide needs rule is statutory (31 U.S.C. § 1502) and is further described in the Government Accountability Office's publication Principles of Federal Appropriations Law, Third Edition, Volume 1, familiarly known as the Red Book as follows:

A fiscal-year appropriation may be obligated only to meet a legitimate, or bona fide, need arising in, or in some cases, arising prior to but continuing to exist in, the fiscal year for which the appropriation was made. (Red Book, p. 5-11)

Because an obligation occurs when GSA accepts a customer's funds, there must be a documented bona fide needs assessment at the time the RWA is accepted. In practice, this means that there must be, at a minimum, a specific, definite and concise description of the requirements associated with the funds at the time of RWA acceptance.

8.Check if an amended RWA. If yes, indicate the dollar amount of the change, the previous total authorized amount, and the new total authorized amount.

9A. Enter billing type: O=Intergovernmental Payment and Collection (IPAC); N=Non-IPAC (federal customer paying by check or credit card); I=Interfund (GSA Internal Customer only); and P=Prepaid (non-federal customers paying via check or credit card). FOR

CREDIT CARD PAYMENTS: If federal customer, use Billing Type N and pay each bill at the Department of the Treasury's Pay.gov website (Block 10A must be empty). If non-federal customer, use Billing Type P and prepay in full at the Pay.gov website.

9B. Enter billing terms: A=Advance, M=Monthly, Q=Quarterly. Non-federal customers leave this block empty.

10A. Enter the 8-character agency location code Treasury Pay-Station Designator. NOTE: If paying by credit card leave this block empty.

10B. DOD IPAC Only.

10C. Mandatory for Internal Revenue Service Customers; optional for all others. Enter the appropriate Requisition ID number.

11A-B. Enter the requested project start and completion dates for severable services (e.g., overtime utilities from March 1st to March 31st). For non-severable services, these dates are optional. NOTE: This should not be used as the agreed-upon initial contract award date; that information should be entered in Block 24A.

12.Enter the total dollar amount approved for funding. This dollar amount must match the cost estimate provided by GSA.

13A. This data will print on most billings. Enter agency accounting information (limited to 130 characters). For GSA Internal/ Interfund customers, the agency accounting data must include, at a minimum, Organization Code, Function Code, Budget Activity, and the SGL Account.

13B. Enter the fiscal year of the agency funds.

13C. Check the appropriate fund type. Fund types may cite one of the following types of appropriations:

•Annual - An appropriation provided for a specified fiscal year and available for obligation only during the fiscal year for which made.

•Multiple Year - An appropriation available for obligation for a definite period in excess of one fiscal year.

•No-Year - Funding available for obligation without fiscal year limitation.

•RECOVERY ACT - Funding provided through economic recovery legislation. GSA-PBS will issue unique numbers for RWAs tied to economic recovery legislation to ensure that applicable reporting requirements are met. If you mark the RECOVERY ACT checkbox, you also must indicate the type of funding (i.e., annual, multiple year, or no-year) using one of the above checkboxes.

13D. Enter the expiration date of the obligational authority for the funds, if funds are annual or multiple year. For example, if the funds cite an annual appropriation for FY 2011, the expiration date entered would be 9/30/2011. Do not complete this block if a no- year appropriation is marked in Block 13C.

13E. Enter the Agency/Customer Business Partner Network/Data Universal Numbering System Number (BPN/DUNS). For DOD, this is the DOD Activity Address Code (DODAAC) number.

13F. For Ordering Agency Use Only. Enter number that references this purchase (e.g., agency internal control number).

13G. Enter the Treasury Account Symbol (required for IPAC billings). Valid Treasury Account Symbols can be found on the Department of the Treasury's FAST Book at http://www.fms.treas.gov/fastbook.

14A-E. Enter the appropriate Requesting Agency finance billing contact information, including the e-mail address of a finance representative who can address any billing issues.

GSA 2957 (REV. 2/2011) PAGE 4