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usuant to the terms of the above numbered contract and in consideration the same stated above, which has been paid or is to be paid to the petractor, or its muignons, the Contractor, upon payment of the muld see by the UNITED STATES OF AMERICA (hereinafter called the

overnment), does remise, release, and discharge the Government, its officers, agents, and employees, of and from all liabilities, obligation alms, and demanda watsoever under or ertaling from the auld contract, except:

1. Specified claims in stated amounts or in estimated amounts where the amounts are not wwwceptible of exact statement by the Contractor, as follows: (or state "None")

2. Clatans, together with resonable apenas incidental thereto, based upon the liabilitie the Contractor to theird parties artoing out of the performance of the contract, whaleh are not known to the Contractor a the date of the execution of the relemne end of whulich the Contractor give notice la writing to the Contracting Officer within the period specified in sid contract; and

3. Claloms for reimbursement of costs (other than expenses of the Contractor by reason of Wales indemnification of the Government agaimat patent liability) including reasonable expenses incidental thereto, incurred by the Contractor under any provisions of the said contract relating to patente.

The Contractor agrees, in connection with patent matter and with cleluas which are not released a set forth above, that it will comply with all provisions of the said contract, provisions of the said contract, including without limitation those provisions relating to notification to the Contracting Micer and relating to the defense or prosecution of litigation.

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TITLE

NOTE:

In the case of a corporation, witnenu are not required but the below statement must be completed.

secretary of the corporation named - Contractor in the foregoing release; that who signed sold release on behalf of the Contractor was then

of wald corporation; release was duly signed for and in behalf of auld corporation by authority of its governing body and is within the scope of its corporate powera

(CORPORATE SEAL)

DOTCOV.W (DOC)

MMOUS ON OBSOLETE

AUTHORIZED FOR LOCAL RENODUCTION

DEPARTMENT OF TRANSPORTATION
EMPLOYEE CLAIM FOR WAGE RESTITUTION

OMB Control No. 2105-0517
Expiration Date: 4/30/97

Public reporting burden for this collection of information 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 aspect of this collection of information, including suggestions for reducing this burden, to the FAR Secretarial (VRS). Office of Federal Acquisition and Regulatory Policy. GSA, Washington, D.C. 2040s, and to the Office of Management and Budget, Paperwork Reduction Project (2105-0517). Washington, D.C. 20503.

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This claim constitutes the total amount claimed due and unpaid for the period of employment indicated.

ADDRESS OF EMPLOYEE

SIGNATURE OF EMPLOYEE

Form DOT F 4220.7 (REV.1074) (EXCEL)

PREVIOUS EDITION OBSOLETE

AUTHORIZED FOR LOCAL NEPROOUCTION

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Date contractor's property control system approved?

Approved by whom?

Name of Agency/Office

Property

Class
(Soo FAR 45.5)

Starting Balance
Total

Total
Acquisition Quantity
Cost

(in acres
(in dollars)

or units)

Items
Added
in $

Items
Deleted

in $

Ending Balance Total

Total Acquisition Quantity Cost

(in acres (in dollars)

or units)

a. Land & Rights Therein

b. Other Roal Property

c. Plant Equipment

d. Special Test Equipment

e. Special Tooling

f. Materials in Stock (when total

value exceeds $50,000)

NOTE: This report shall include all Government property (i..., property furnished by the Government, or acquired or fabricated by the contractor or subcontractors). By signature hereon, the contractor's property administrator declares that the report was prepared from the contractor's records that are required by FAR 45.5.

10. Typod Name of Contractor Property Administrator

11. Signatur und Date

Para DOT 001.aam (EXCEL

REVIOUS EDITION OBSOLETE

AUTHORIZED FOR LOCAL REPRODUCTION

OMB Control No.: 21654517

CONTRACTOR'S ASSIGNMENT OF
REFUNDS, REBATES, CREDITS, AND OTHER AMOUNTS

Berndon Date: 1311

Public reporting burden for this collection of information is estimated to average 1 hour per respons, lectuding the time for reviewing Instruction marching
exdating 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 spect of this collection of information, including creations for reducing the burden, to the FAR Secretariat (VRS), Office of Federal Acquation and
Regulatory Policy, GSA, Washington, D.C. 2040$; and to the Office of Marengut und Budget, Paperwork Reduction Project 2108-4517), Washington, D.C. 20903.

Pursuant to the terms of Contract No.

and in consideration of the reimbursement of costs and payment of fee, as provided in the said contract and any assignment thereunder,

(hereinafter called the Contractor) does hereby:

1. Assign, transfer, set over the release to the UNITED STATES OF AMERICA (hereinafter called the
Government), all right, title and interest to all refunds, rebates, credits or other amounts (including
any interest thereon) arising out of the performance of the said contract, together with all the rights of
action accrued or which may hereafter accrue thereunder.

2. Agree to take whatever action may be necessary to effect prompt collection of all refunds, rebates, credits or other amounts (including any interest thereon) due or which may become due, and to promptly forward to the UNITED STATES TREASURER checks (made payable to the Treasurer of the United States) for any proceeds so collected. The reasonable costs of any such action to effect collection shall constitute allowable costs when approved by the Contracting Officer as stated in the said contract and may be applied to reduce any amounts otherwise payable to the Government under the terms hereof.

3. Agree to cooperate fully with the Government as to any claim or suit in connection with refunds, rebates, credits or other amounts due (including any interest thereon); to execute any protest, pleading, application, power of attorney or other papers in connection with; and to permit the Government to represent it at any hearing, trial, or other proceeding arising out out of such claim or suit.

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By signature hereon, I,

declare that I am the

(official title) of the corporation named as Contractor in the foregoing assignment; that

signed said assignment on behalf of the Contractor was then

of said corporation by authority of its governing body and is within the scope of its corporate powers.

(CORPORATE SEAL)

Form DOT 4220.40 (REV. 207 Exca

MEVIOUS Dmow OCCOLATE

AUTMONDED FOR LOCALOouchou

OMD Control No. 2148-4817

CUMULATIVE CLAIM AND
RECONCILIATION STATEMENT

Public reporting burden for this collection of Information scol d to werego 1 hour per response, clude the for reviewing mestructions marching
endastlang data saurons, gathering and maintaining the data needed, and completing and reviewing the collection Information Seed comments regarding this burden
estimate or any other spect of this collection of information, Inchanting sucretions for reducing the burden, to FAR Secretaries (VRS), Office of Federal Acquisition and
Regulatory Palley, GSA, Washington, D.C. 2009; end to the Omee Management and budget, Paperwork Reduction Project Clas 4517), Washington, D.C. 20003.

1. Name of Contractor
2. Address of Contractor

3. Contract No.
4. Delivery/Task Order No.

5. The total amount claimed under the above numbered contract, delivery order, or task order number is as follows:

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.............................................................................................

a Direct Labor...............
b. Direct Material..........
c. Other Direct Costs.....
d. Overhead
e. G&A..............................................................................
f. Subcontract Cost......................................
& Total Costs (5a through 51).........
h. Fixed Fee......
i Total Amount Claimed..................

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..................................................................

6. Total amount due under the above numbered contract, delivery order, task order is as follows:

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y as the (F Name)

(Title) of the above named contractor, declare that the above statements are correct in accordance with the records of the contractor.

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