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To to the term of the above wwwbered contract and he creadoration of the sumn stated above, which has been paid or lo to be pailed to the Contractor, orlop es, de Contractor, upon payment of the old mam by the UNITED STATES OF AMERICA (hereinafter called the Goran t), docerent, relem, od dlecharge the Government, la oflean, agents, and comployees, of end frova all liabilities, obligation, chalana, and demands whatsoever under or arising from the sald contract, except:

1. Specie de la stated mounts or to catimated amounts where the amounts are not conceptible of exact statement by the Contractor, follows: (or state "None)

2 Chandanes, together witte ressonable as powers incidental thereto, based upon the Webliches of the Contractor to theird parties erteling out of the portance of data contract, welch are not known to the Contractor on the date of the execution of this release and of watch the Contractor show othea la wreturn to the Contracting Omeer within the period specified in the old contract; and

1. Chakes for redenbursement of conte (other this expenses of the Contractor by reason of hilo Indemnification of the Government against patent kablity) luchadlang reasonable a penses Incidental therete, lancurred by the Contractor under any proviolons of the salud contract relating to patenta.

The Constructor egrera, la connection with patent matter and with clealumo wtulcth are not relenord as set forth above, that will comply with all p loc he contract, prontalon of the weld contract, including without limitation those provtalons relating to modification to the Contracting Vier mod red to the defensor prosecution of litigation

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

- of aald corporation; and for and in behalf of old corporation by authority of Its governing body and be within the scope of its corporate power

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(CORPORATE SEAL)

DOT O

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MIMOUN EMON ORIOLET

AUTHORIZED ME LOCAL MODUCTION utor. UNIV.14 ENEU

DEPARTMENT OF TRANSPORTATION
EMPLOYEE CLAIM FOR WAGE RESTITUTION

Ows Control No 7105 0817
Expiration Date: 30007

Public reporting burden for this collection of information is estimated to everago 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 Sand comments regarding this burden estimate or any mpact of this collection of information, including augustions for reducing this burden, to the FAR Secrotariat (VRS). Orice of Federal Acquisition and Regulatory Policy. GSA Washington, DC. 2008, and te the Office of Management and Budget, Paperwork Reduction Project (2108-0817), Washington, D.C. 2013.

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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

retvous enimow ooOLITE

AUTHORIZED FOR LOCAL REPRODUCTION

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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 horoon, the contractor's property administrator declares that the report was prepared
trom the contractor's records that we required by FAR 46.6.

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Publike reporting burden for this collection of information is e sted to mergo 1 pre c e the winding struct urile endating data sources gilering and maintaining the data meded, completing and reviewing the cocina deformation Secundar iage estimate any other pect of this collection of laboration, including como formodestag this tarde, o de TAR Secretaries (VI), Ole Pedere Aco Regulatory Policy. GSA, Wellington, D.C. 4; d to the Old Ma

n

Reduction Project Bit 817), W ington, D.C. 2000.

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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.

IN WITNESS WHEREOF, this assignment has been executed this

day of

BY:

(CONTRACTOR)

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)

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

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e Direct Labor.
to Direct Material.........
& Other Direct Costs...........

Overhead..........
& G&A.......
f Subcontract Cost.............................................
& Total Costs (5a through 51)......................

Fixed Fee................... | 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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, as the ( Nome)

(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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