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to the

f the above numbered contract and in consideration of the sum stated above, which has been paid or is to be paid to the its nesignees, the Contractor, upon payment of the said sum by the UNITED STATES OF AMERICA (hereinafter called the

, does remise, release, and discharge the Government, its officers, agents, and employees, of and from all liabilities, obligations,

ms, and demands whatsoever under or arising from the said contract, except:

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

2. Claims, together with reasonable expenses incidental thereto, based upon the liabilities of the Contractor to third parties arising out of the performance of this contract, which are not known to the Contractor on the date of the execution of this release and of which the Contractor gives notice in writing to the Contracting Officer within the period specified in the said contract; and

3. Claims for reimbursement of costs (other than expenses of the Contractor by reason of his indemnification of the Government against patent lability) including reasonable expenses incidental thereto, incurred by the Contractor under any provisions of the said contract relating to patents.

The Contractor agrees, in connection with patent matters and with claims which are not released as set forth above, that it will comply with all provisions of the said contract, provisions of the said contract, including without limitation these provisions relating to notification to the Contracting Officer and relating to the defense or prosecution of litigation.

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› was duly signed for and in behalf of said corporation by authority of its governing body and is within the scope of its corporate powers.

Put DOT 430.4 (LEV. 207) (EXCEL)

(CORPORATE SEAL)

PREVIOUS EDITION OBSOLETE

AUTHORED FOR LOCAL REPRODUCTION

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 Secretariat (VRS), Office of Federal Acquisition and Regulatory Policy, GSA, Washington, DC. 20405; and to the Office of Management and Budget, Paperwork Reduction Project (2105-0517), Washington, DC. 20603.

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

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NOTE: This report shall include all Government property (i.e., 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.

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CONTRACTOR'S ASSIGNMENT OF

REFUNDS, REBATES, CREDITS, AND OTHER AMOUNTS

OMB Central No.: 2105-4517

Expiration Date: 4/30/97

Public reporting burden for this collection of information is estimated to average 1 hour per ponse, including the time for reviewing instructions marching
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 other aspect of this collection of information, including suggestions for reducing this burden, to the FAR Secretariat (VRS), Office of Federal Acquisition and
Regulatory Policy, GSA, Washington, D.C. 20485; and to the
iget, Paperwork Reduction Project (2105-8517), 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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5. The total amount claimed under the above numbered contract, delivery order, or task order number is as follows:

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

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

Form DOT F 4220.48 (REV. 2/97) (EXCEL)

PREVIOUS EDITION OBSOLETE

(Signature)

AUTHORIZED FOR LOCAL REPRODUCTION

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