# DLAD PART 53 – FORMS

- SUBPART 53.2 – PRESCRIPTION OF FORMS
- SUBPART 53.2 – PRESCRIPTION OF FORMS

- 53.213 Small purchase and other simplified purchase procedures.

- 53.213-90 Blanket purchase agreement delivery ticket (DLA Form 470).
- 53.213-91 Shipping Instruction (DLA Form 1224).
- 53.213-92 Request for Quotation (DLA Form 1231).

- 53.219 Small business and small disadvantaged business concerns.

- 53.219-90 Referral of Small Business for Certificate of Competency (CoC) Consideration (DLA Form 1756).

- SUBPART 53.3 – ILLUSTRATION OF FORMS

- 53.300 General.

- SUBPART 53.90 – FORMATS AND TEMPLATES

- 53.9001(a) Appointment of ordering officer.
- 53.9007 Acquisition Planning
- 53.9007(a) Template - Streamlined Acquisition Plan (SAP)
- 53.9013 Simplified acquisition procedures.
- 53.9013(a) Simplified Acquisition Award Documentation The following format shall be used to document the basis for award and determination of price reasonableness for simplified acquisitions as prescribed in 13.106-3(b).
- 53.9013(b) Template - Market Research for Commercial Items and Commerciality Determination Memorandum for Record
- 53.9013(c) Template - Commercial Evaluation/Award Documentation
- 53.9015 Contracting by Negotiation
- 53.9015(a) Price Negotiation Memorandum Checklist Competitive.
- 53.9015(b) Price Negotiation Memorandum Checklist Non-Competitive.

PART 53 – FORMS

TABLE OF CONTENTS

(Revised March 9, 2018 through PROCLTR 2018-02)

SUBPART 53.2 – PRESCRIPTION OF FORMS

53.213 Small purchase and other simplified purchase procedures.

53.213-90 Blanket purchase agreement delivery ticket (DLA Form 470).

53.213-91 Shipping Instruction (DLA Form 1224).

53.213-92 Request for quotation (DLA Form 1231).

53.219 Small business and small disadvantaged business concerns.

53.219-90 Referral of small business for certificate of competency (CoC) consideration (DLA Form

1756).

SUBPART 53.3 – ILLUSTRATION OF FORMS

53.300 General

SUBPART 53.90 – FORMATS AND TEMPLATES

53.9001 Appointment of ordering officer.

53.9007 Acquisition Planning

53.9013 Simplified acquisition procedures.

53.9015 Contracting by Negotiation

SUBPART 53.2 – PRESCRIPTION OF FORMS

(Revised September 19, 2016 through PROCLTR 2016-09)

53.213 Small purchase and other simplified purchase procedures.

53.213-90 Blanket purchase agreement delivery ticket (DLA Form 470).

This form may be used when supplies or services are acquired by means of a blanket purchase agreement (BPA).

(a) General. The Defense Logistics Agency (DLA) Form 470 is a cut sheet form and is designed to be used by the vendor as an acknowledgment of a call, notice of shipment, packing list, and invoice. This form eliminates the need for preparation, by the Contractor, of separate forms for these purposes. Also, Government personnel requiring information on these forms will receive it on a standard format.

(b) Procedure. A supply of the forms may be provided by the contracting office to each Contractor who has entered into a BPA with the center. Upon the placing of a call, the Contractor may be required to complete the BPA delivery ticket based on information contained in the written or oral call in accordance with detailed instructions to be provided by the contracting office.

(c) General instructions for preparation of DLA Form 470. After the placing of each call, complete the call, complete the form in accordance with the general instructions below, and any specific instructions received with the placing of the call.

(1) Block 11. This is the date the supplies are to reach destination, not the date of shipment. Convert the number of delivery days the Government offered to an actual date. For example, if the Government offered a 30-day delivery and received the oral or written call on 1 October, enter 10/31/YY as the required date.

(2) Block 12. This is the date the supplies are to be shipped, not delivered.

(3) Blocks 13 through 19. Information for these blocks will be furnished by the contracting office at the time of the call. Enter the name and address of the consignee in block 15.

(4) Blocks 21 through 23. Entries in these blocks will be made at the time of shipment. Enter actual date shipped or delivered. No partial shipments to a particular destination may be made. If more than one shipment is made against a call, prepare two copies of this form for shipment. Copies of the shipping documents may be attached as an alternative to completing blocks 21 and 22.

(5) When using the form as an acknowledgment of call. Place a check mark on "*" copies of the form in the box "Acknowledgment of call" (block 9).

(6) When using this form as a notice of shipment. Place a check mark in the box "Packing list" (block 9) on "*" copies of the form in the box "Notice of shipment" (block 9).

(7) When using the form as a packing list. Place a check mark in the box "packing list" (block 9) on "*" copies of the reproduced form for each consignee. Be sure blocks 21 through 23 have been completed, as applicable, on the forms used. Send "*" copies to each consignee by placing copies inside the container or in an envelope attached to the exterior of the container.

(8) When using this form as an invoice. At the end of the billing period, fill in "*" copies of the reproduced form which includes the shipment data for all destinations of that call as follows:

(i) Place a mark in the box marked invoice (block 9) of each copy of the form.

(ii) Sign and date blocks 24 and 25 of the top copy only of the form. If the BPA under which this call was issued does not provide for the fast payment procedure, the top copy must contain the signature and date (blocks 27A and 27B) of the authorized Government representative receiving and/or accepting for the Government.

"*" The number required shall be in accordance with the needs of the contracting office.

53.213-91 Shipping Instruction (DLA Form 1224).

This form is used against automated simplified acquisitions.

53.213-92 Request for Quotation (DLA Form 1231).

This form is used against automated simplified acquisitions.

53.219 Small business and small disadvantaged business concerns.

53.219-90 Referral of Small Business for Certificate of Competency (CoC) Consideration (DLA Form 1756).

(a) DLA Form 1756 may be used to provide information for CoC referrals as required by FAR 19.602-1 and DFARS 219.602-1.

(b) General instructions for preparation of DLA Form 1756:

(1) The name, size status, and total dollar value of the next low offeror should be identified, however, referrals shall not urge a conclusion based upon the size status of the second low offeror.

(2) The remaining blocks of the form are self-explanatory.

SUBPART 53.3 – ILLUSTRATION OF FORMS

(Revised April 18, 2014 through PROCLTR 2014-64)

53.300 General.

DLA forms are electronically maintained at https://www2.dla.mil/officialforms/pages/DLAformsinventory.html

SUBPART 53.90 – FORMATS AND TEMPLATES

(Revised March 9, 2018 through PROCLTR 2018-02)

53.9001(a) Appointment of ordering officer.

As prescribed in 1.603-3-91(c)(1), use the following appointment letter for ordering officers:

Appointment of Ordering Officer [Contracting officer insert IDC or BPA number and name of procuring organization] 1. Appointment. Under the authority of DLAD 1.603-3-91, you are hereby appointed as an Ordering Officer with authority as described in paragraph 2 below. Your appointment is effective on [contracting officer insert date]. This appointment automatically terminates when the Indefinite Delivery Contract (IDC) or Blanket Purchase Agreement (BPA) is completed. Your appointment may also be terminated in accordance with paragraph 4 below. 2. Authority, Limitations, and Requirements. Your ordering authority is only applicable to [contracting officer insert IDC or BPA number]. Your appointment is subject to the following limitations and requirements: a. You are not authorized to— (1) Delegate your ordering authority. (2) Place an order for supplies or services not expressly within the scope of the IDC or BPA. (3) Take any action that could be considered an alteration of the terms and conditions of the IDC or BPA in any way, either directly or by implication. (4) Take any action that could be considered a termination of the IDC or BPA in any way, either directly or by implication. (5) Issue modifications to the IDC, BPA, or individual orders. (6) Issue instructions to the contractor to start or stop work. (8) Additional limitations: [contracting officer insert if applicable]. b. You shall— (1) Place orders for supplies or services only when expressly within the scope of the IDC or BPA. (2) Promptly notify me if you recommend increasing the quantity or dollar value or extending the ordering period to meet emergency requirements, if the contract terms and conditions permit. (3) Establish and maintain an official ordering officer file for each IDC and BPA for which you are authorized as an ordering officer. At a minimum, you shall include in each file the appointment letter and a spreadsheet listing all orders issued by you. (4) Provide the list of orders to me by the [contracting officer insert] day of each month. (5) Additional requirements: [contracting officer insert if applicable]. 3. Standards of Conduct and Contracting Action Reporting Requirements. a. You shall comply with the standards of conduct prescribed in DoD Directive 5500.07, Standards of Conduct, and DoD 5000.07-R, The Joint Ethics Regulation (JER), and FAR Subparts 3.1 and 3.2. b. You shall provide me information required for contracting action reporting purposes in the manner and the time specified. (Refer to DFARS 204.6.) 4. Termination of Appointment. a. Your appointment may be terminated at any time and shall be terminated in writing; except that your appointment is automatically terminated when the contract is completed or when you leave Government employment. b. If you are separated from Government service while this appointment is in effect, you shall promptly notify me in writing. Your appointment shall automatically be terminated on the date you are separated from Government service. c. If you are reassigned from your present position while this appointment is in effect, you shall promptly notify me in writing. I will terminate your appointment in writing if you are reassigned to a location or position that is inconsistent with continuing as an ordering officer under this appointment. d. Your appointment will be terminated if— (1) You exceed or fail to perform within the appointment authority. (2) You fail to complete assigned corrective actions noted during oversight reviews. 5. Disposition of completed ordering officer files. Upon completion of the IDC or BPA, you shall provide me any hard copy records you maintained. If your appointment is terminated before IDC or BPA completion, you shall provide the records to me and your successor. 6. Acknowledgement of Receipt. You are required to acknowledge receipt and understanding of this appointment by signing below. Return a copy of the signed appointment letter to me. ______________________________ _________________________________ ________ Contracting Officer Name Contracting Officer Signature Date ______________________________ _________________________________ ________ Ordering Officer Name Ordering Officer Signature Date

53.9007 Acquisition Planning

53.9007(a) Template - Streamlined Acquisition Plan (SAP)

The following format may be used as prescribed in 7.103(d)(i)(B).

For Official Use Only Source Selection Information -- See FAR 2.101 and 3.104 Streamlined Acquisition Plan (SAP) (Complete and select the box that is appropriate for the acquisition situation) Date: Contracting office:       Contracting officer name: Requiring activity:       Voice (DSN): Project title:       Fax (DSN): Supply criticality: Contracting officer’s e-mail address: Purchase request (PR) or control number: ☐ Construction ☐ Service ☐ Supply ☐ Research and development (R&D) a. Product Service Code: (Specify for services) b. Services Portfolio Category: (Specify for services) I. Brief description of requirement (FAR 7.105(a)(1)) a. Government estimate: $       (include all options and surge values) b. Period of performance       (include options) c. Delivery schedule: II. Proposed acquisition approach a. Extent of competition: ☐ Full and open competition ☐ Other than full and open competition* * FAR 6.3 authority (Specify): ☐ Full and open after exclusion of sources ☐ Competitive non-DoD ☐ Mandatory use policy, including waivers (e.g., under Part 8) ☐ Limited sources (e.g. under Part 8.405-6): b. Small business set-aside: (See FAR Part 19) ☐ Competitive small business set-aside (SBSA) ☐ Competitive 8a ☐ Sole source 8a ☐ Service Disabled Veteran Owned Small Business (SDVOSB) Set-Aside ☐ SDVOSB sole source ☐ Historically underutilized business zone (HubZone) Sole Source ☐ HubZone set-aside ☐ Small disadvantaged women owned business (SDWOB) ☐ Economically disadvantaged women owned small business (EDWOSB) ☐ Historically Black colleges and universities / minority institutions (HBCU/MI) ☐ Not applicable (NA) (If acquisition is unrestricted) ☐Other (Specify): c. Procedures: (Check all that apply) ☐ FAR 8.404 (GSA/Non-DoD Competitive) ☐ FAR 12 Commercial Items ☐ FAR 13 Simplified Acquisition Procedures ☐ FAR 14 Sealed Bidding ☐ FAR 15 Negotiation ☐ FAR 36 Construction and Architect and Engineer (A&E) and design build d. Contracting method ☐ Invitation for bid (IFB) ☐ Competitive request for proposal (RFP) ☐ Sole source RFP ☐ Other (fill-in) e. Basis of award: ☐ Sealed bid – Part 14 ☐ Negotiation – Part 15 ☐ Lowest price technically acceptable ☐ Performance price trade-off without technical factors/proposal ☐ Performance price trade-off with technical factors/proposal ☐ Full trade off source selection (an acquisition plan is highly recommended) ☐ General Services Administration (GSA)/non-DoD competitive ☐ Other (explain): Identify evaluation factors: f. Contract type (Check all that apply): ☐ Fixed-price ☐ Time and material/labor hour agreements ☐ Economic price adjustment ☐ Incentive ☐ Award fee ☐ Cost-reimbursement ☐ Redetermination ☐ Indefinite delivery contract (IDC) ☐ Multiply Award ☐ Single Award (Provide rationale why single award) ☐ Other (Specify): g. Sustainability: ☐ Contains sustainability requirements. ☐ Sustainability exception applies: (Specify) ☐ Sustainability requirements waived, approved by: (Specify) h. Other considerations (Check all that apply): ☐ Progress payment ☐ Warranty ☐ First article test (FAT) ☐ Government furnished property(GFP) / Government furnished material (GFM) / Government furnished equipment (GFE) involved ☐ Other (specify). Other items/considerations may include, Non-Economy Act or Economy Act assisted acquisitions and use of reverse auction) III. Prior procurement history: (If applicable) IV. Market research: (Discuss the purpose, nature, extent, involved personnel/offices and results/status, commerciality, and estimated completion date of any market research initiated/to be initiated in support of the instant purchase request or anticipated future requirements (see also FAR, DFARS, and DLAD Parts 10, 11) V. Problems /risk/vulnerabilities (See FAR 7.105 and DFARS PGI 207.105) VI. Projected key milestone dates: Receive purchase request (PR): Issue solicitation: Receive bids/offers: Complete evaluations: Award contract: Contract start: _________________________________ ____ Contracting Officer Name and Signature Date VII. Approvals: ** The following section is to be completed by reviewer/approving official. ** Reviewer’s name:       Reviewer’s DSN/ phone number: Reviewer’s e-mail: ☐ Streamlined acquisition plan (SAP) approved as submitted ☐ SAP conditionally approved subject to comments below ☐ SAP disapproved (reviewers are required to include comments below) ☐ Requirement has been reviewed and validated by (specify): Reviewer’s comments: Reviewer’s signature: ______________________ ** The following section is to be completed by the small business specialist when required** ☐ Small business specialist coordination _____________________________ Small business specialist's comments: ** The following section is to be completed by the competition advocate when required** ☐ Competition Advocate coordination _____________________________ Competition advocate’s comments:

53.9013 Simplified acquisition procedures.

53.9013(a) Simplified Acquisition Award Documentation The following format shall be used to document the basis for award and determination of price reasonableness for simplified acquisitions as prescribed in 13.106-3(b).

Simplified Acquisition Award Documentation

(FOR OFFICIAL USE ONLY - SOURCE SELECTION INFORMATION – SEE FAR 2.101 AND 3.104)

Acquisition Specialist: PR#: ________________________

PRC Code__________________________ NSN: __________________________

Basis for Award – Price Reasonableness Determination – FAR 13.106-3(a): (Check as applicable and explain*)

[ ] Fair and Reasonable – Adequate Price Competition – Manufacturer Competition

[ ] Fair and Reasonable – Adequate Price Competition Among Providers of Services

[ ] Fair and Reasonable – Adequate Price Competition – Dealer/OEM Competition

[ ] Fair and Reasonable – No Competition (single quote or noncompetitive price range)

[ ] Commercial Item $ per unit

[ ] Market Research

[ ] Federal Supply Schedule (FSS) Number: ________________ FSS Price: $ ________________

[ ] Independent Government Estimate

[ ] Comparison of the proposed price with prices found reasonable on previous purchases

Contract:_________________________ Unit Price: $____________ Quantity:_____________

Price Reasonableness Code (PRC) – DLAD 15.406-3(a)(11):____________

[ ] Comparison of similar items: NSN: ________________ Unit Price: $________________

Contract:_________________________ Quantity:____________ PRC:_____________

[ ] Contracting Officer’s knowledge of the item

[ ] Any other reasonableness basis (i.e. Informal Cost Breakdown, Set by law or regulation, or other FAR Part 15 procedures)

*Narrative:

DFARS 217.7505 Sole Source Price Increase Certification:

Price has increased 25% or more within the past 12 months. [ ] Yes [ ] No. If “Yes”, the price has been evaluated and justified. Required notification prior to award completed.

Best Value Determination: (Required if Awarding to Other Than Lowest Price Highest Scored):

*Narrative:

Other Determinations: (Check as applicable and explain as needed*)

[ ] Procurement is a First Time Buy

[ ] SAM.gov checked; awardee not proposed for suspension/debarment or debarred IAW FAR 9.105-1.

Date SAM Checked: ___________

Contracting Officer’s signature on the award document constitutes concurrence with all determinations made above.

53.9013(b) Template - Market Research for Commercial Items and Commerciality Determination Memorandum for Record

The following format shall be used to document market research for commercial items as prescribed in 13.501(b)(1).

MEMORANDUM FOR RECORD

SUBJECT: Market Research for Commercial Items (FAR 10.002, FAR 2.101, and FAR 13.5)

Market research has been conducted prior to solicitation:

Solicitation # , NSN(s) , Item

PART I

In accordance with FAR 10.002(b) and FAR 2.101, Definitions, a review has been conducted of the item description(s) to determine if commercial items or non-developmental items are available to meet the Government’s needs or could be modified to meet the Government’s needs to determine the following:

• Whether items of a type are customarily available in the commercial marketplace; annotate evidence of actual sale, lease, or license to the general public:

• Whether items of a type are customarily available in the commercial marketplace with modifications; annotate evidence of actual sale, lease, or license to the general public and type of modification:

• Whether items are used exclusively for governmental purposes; annotate evidence that the items were (1) developed exclusively at private expense, and (2) sold competitively in substantial quantities to multiple state and local Governments:

• Customary practices regarding customizing, modifying or tailoring of items to meet customers’ needs and associated costs; annotate evidence of customary availability of the modification in the commercial marketplace or the technical relationship between the modified items:

• Customary practices, including warranty, buyer financing, discounts, contract type considering the nature and risk associated with the requirement, etc., under which commercial sales of the products or services are made:

• The applicability of any laws and/or regulations unique to the item being acquired:

• The availability of items that contain recovered materials and items that are energy efficient; the distribution and support capabilities of potential suppliers, including alternative arrangements and cost estimates; and the size and status of potential sources:

____________________________________________________________________________________________

PART II

Please check the applicable block(s) for techniques utilized to conduct market research and determine commerciality:

( ) Commercial-Off-the-Shelf Field is coded

( ) If item has been coded in SAP as commercial, but non-commercial practices are required (e.g., QCCs, packaging, etc.) the justification for the use of these practices has been entered in SAP in the internal comments field.

( ) Contacted knowledgeable individuals in Government and industry regarding market capabilities to meet requirements;

( ) Reviewed the results of recent market research undertaken to meet similar or identical requirements;

( ) Published formal requests for information in appropriate technical or scientific journals or business publications;

( ) Queried the Government-wide database of contracts and other procurement instruments intended for use by multiple agencies available at https://www.fpds.gov and other Government and commercial databases that provide information relevant to agency acquisitions;

( ) Participated in interactive, on-line communication among industry, acquisition personnel, and customers;

( ) Obtained source lists of similar items from other contracting activities, agencies, trade associations, or sources;

( ) Reviewed catalogs and other available product literature published, or on-line, by manufacturers, distributors, and dealers;

( ) Queried the Central Contractor Registration (CCR) via the System for Award Management (SAM) for small business sources, as applicable. (See FAR and DFARS Part 4 for information on SAM).

( ) Other (attach supporting documentation to include a review of the Material Master in SAP):

SUMMARY OF MARKET RESEARCH:

The Acquisition Specialist contacted the Product Specialist

Name Date

Product Specialist Concurrence Received (Y/N): ________________________________

If “Yes,” has the Material Master been updated: ______________________________

If “No,” state reason for non-concurrence and how non-concurrence resolved: ___________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

CONCLUSION:

Based on the market research conducted, item(s) to be solicited against subject solicitation have been determined to be commercial.

( ) Commercial ( ) Non-Commercial

APPROVALS:

______________________ __________ ___________________________ ___________

Acquisition Specialist Date Contracting Officer Date

_______________________________________________________ ___________

Approving Official (one level above KO – for > $1M only) Date

53.9013(c) Template - Commercial Evaluation/Award Documentation

The following format shall be used to document evaluation and award information, and the determination of responsibility, as prescribed in 13.501(b)(1).

MEMORANDUM FOR RECORD SUBJECT: COMMERCIAL ITEM AWARD DETERMINATION UNDER 13.5 Part I Determination of Responsibility: The awardee [insert CAGE code] is hereby determined responsible. Part II The Price is determined fair and reasonable based on: Adequate competition If only one response was received, the price is determined fair and reasonable based on: Market Research: (insert narrative below); Comparison of proposed price with prices found reasonable on previous purchases (insert narrative below); Current price lists, catalogs, or advertisements. However, inclusion of a price in a price list, catalog, or advertisement does not, in and of itself, establish fairness and reasonableness of the price (insert narrative below); Comparison with similar items in a related industry (insert narrative below); The contracting officer’s personal knowledge of the item being purchased (insert narrative below); Comparison to an independent Government estimate (insert narrative below); OR Any other reasonable basis (insert narrative below) Additional Remarks: Part III Award Justification: (Insert narrative) APPROVALS: Acquisition Specialist Date Contracting Officer Date

53.9015 Contracting by Negotiation

53.9015(a) Price Negotiation Memorandum Checklist Competitive.

Contracting officers must use format in the following checklist as prescribed in 15.406-3.

PRICE NEGOTIATION MEMORANDUM CHECKLIST COMPETITIVE
Contents Checklist | Yes | No | N/A
“FOR OFFICIAL USE ONLY (FOUO)” at the top and bottom of first and last page, and bottom of each page containing FOUO (DOD Manual 5200.01, Vol 4) |  |  |
1. Subject |  |  |
a. Contractor name, division or group and location |  |  |
b. Contract or RFP number |  |  |
c. Item or service acquired |  |  |
2. Introductory summary |  |  |
a. Contractor and proposal selected for award and date |  |  |
b. Offerors |  |  |
c. Tabular Summary of: proposed price, government estimate, and final proposal revision |  |  |
Major Price Items or CLINS |  |  |
Total |  |  |
Profit/fee % |  |  |
CPAF (base and award fee) ($ and %) |  |  |
Contract type |  |  |
c. Clearance authority |  |  |
(1) Approval authority |  |  |
(2) Approval date, meeting dates, and participants |  |  |
3. Details |  |  |
a. Description of item or services |  |  |
b. Explain method used for line item or unit prices |  |  |
c. Personnel: List names, title, organization and telephone number of participants in price analysis and as applicable, cost realism discussions |  |  |
d. Significant dates: |  |  |
(1) Proposal date |  |  |
(2) Discussion (s)/date (s) |  |  |
(3) Final proposal revision date |  |  |
(4) Other significant date (s) (acquisition review board dates, competitive range determination, solicitation amendments, etc.) |  |  |
4. Acquisition situation |  |  |
a. Acquisition background |  |  |
b. Discuss period of performance and delivery schedule |  |  |
c. Outside influences or unusual time constraints (i.e., Funding limitations, higher level, Congressional influences) |  |  |
d. Unique features or special pricing provisions (economic price adjustment, incentives, warranties, special progress payments, etc.) |  |  |
5. Evaluation summary |  |  |
a. Reasonableness, completeness, cost realism if applicable, and balance |  |  |
(1) Description of price analysis technique (s) used, results, and appropriateness in determining price reasonableness and completeness |  |  |
(a) Description of the basis of any escalation rates used for adjusting historical prices or for forecasting option year prices. See DoD Contract Pricing Reference Guide, Volume 2 Quantitative Techniques, Chapter 1 Using Price Index Numbers for potential sources of information, calculating adjustments, and other relevant topics. . |  |  |
(b) Description of GSA Schedule prices, if any. Contracting officer must check GSA for any relevant price information and document the results |  |  |
(2) Description of the cost realism analysis technique (s) and their result (s) (if performed) |  |  |
(3) Description of assessment of balanced pricing and any associated risks |  |  |
(4) Document decision to conduct discussions and date (s). Document decision to award without discussions. |  |  |
(5) Description and listing of major differences between the proposal and the final proposal revision prices |  |  |
b. Adequate price competition determination description |  |  |
(1) Basis of determination statement of adequate price competition |  |  |
(a) Best value to the Government and the significance of cost or price to all evaluation factors combined; |  |  |
(b) Lowest evaluated price; or |  |  |
(c) Adequate price competition |  |  |
(2) Definitive statement the offered price selected is fair and reasonable based on adequate price competition. |  |  |
6. Advisory reports and key documents |  |  |
Listing of Government advisory reports (pricing, technical, should cost, etc. Include title, report number and date.) |  |  |
7. Signatures |  |  |
Signature block for contracting officer, and any other signatures required |  |  |
8. Attachments |  |  |
Attachments as identified in the document |  |  |

53.9015(b) Price Negotiation Memorandum Checklist Non-Competitive.

Contracting officers must use format in the following checklist as prescribed in 15.406-3.

PRICE NEGOTIATION MEMORANDUM CHECKLIST NON-COMPETITIVE
PNM Contents Checklist | PNOM | PNM | N/A
“FOR OFFICIAL USE ONLY (FOUO)” at the top and bottom of first and last page, and bottom of each page containing FOUO (DOD Manual 5200.01, Vol 4) |  |  |
1. Subject |  |  |
a. Contractor name, division or group and location |  |  |
b. Contract or RFP Number (as applicable include modification number) |  |  |
c. Item or service acquired |  | NA |
d. Delivery and/or Period of Performance |  |  |
2. Introductory summary |  |  |
a. Date (s) of Negotiation and Agreement | NA |  |
b. Contract action type (new contract, supplemental agreement, etc.) |  | NA |
c. Tabular summary of cost, FCCOM, profit or fee and price: |  |  |
(1) Proposed and objective positions |  | NA |
(2) Proposed, objective and considered negotiated positions | NA |  |
(3) Separate summaries for options, etc. |  |  |
(4) Fee or profit rate for each position |  |  |
(5) Award fee pool for each position (as applicable) Ceiling price and percentage for each position (as applicable for cost contracts) |  |  |
(6) Contract type for each position (FFP, FP/EPA, CPFF, CPAF, etc.) |  |  |
d. Approval authority |  |  |
(1) Approval authority |  |  |
(2) Approval date, meeting date (s), and participants |  |  |
(3) Limitations and specific approving authority conditions |  |  |
3. Details |  |  |
a. Item or service identification: |  |  |
(1) Quantity and type |  |  |
(2) Previous buys for the same or similar items |  |  |
(A) Date (s) of recent buys |  | NA |
(B) Quantity |  | NA |
(C) Contract type |  | NA |
(D) Prior unit or total prices (target and finals if applicable and available: document separately recurring and nonrecurring costs) |  | NA |
(E) Current unit or CLIN prices (may attach) with name of item, NSN, part number, quantities, etc., as applicable (document separately recurring nonrecurring costs) |  | NA |
(F) Summary explanation of significant differences between the instant buy and most recent historical price (s) |  | NA |
(G) Stock Position of Items (include date stock position, current unfilled orders, inventory consumption rate, due-in quantities, etc. Discuss any over or under position) |  | NA |
b. Explain method for line item or unit prices |  |  |
c. Fact-finding and negotiation dates, places, names, titles, and office symbols for the government and the contractor |  |  |
d. Principal government and contractor negotiator identified |  |  |
4. Acquisition situation |  |  |
a. Acquisition background (contract type, pricing, etc.) indefinite-delivery contract and why it does or does not apply, surge and sustainment, etc. |  |  |
b. Period of performance and delivery schedule (address resolution of differences between required, proposed and negotiated) |  |  |
c. Outside influences and unusual time constraints |  |  |
d. Government furnished facilities, equipment or other support unique to this acquisition |  |  |
e. Unique features such as should cost, design-to-cost, life cycle cost, special payment procedures, and special provisions (clauses: savings, EPA, progress payments, performance based payments, validation of critical safety item and date , incentives, etc.) |  |  |
5. Negotiation summary |  |  |
a. Discussion of contractor price analysis, government price analysis, or no analysis performed |  |  |
(1) Price element summary for proposed, objective, and considered negotiated amount. Discuss the position for proposed, objective and considered negotiated positions by topic. |  |  |
(2) Price reasonableness basis or estimating technique (attach exemption or waiver if used instead of certified cost or pricing data). If using GSA schedule, the contracting officer must include a GSA contract for any relevant price information and document the results |  | NA |
(3) Identify submission of data other than cost or pricing data necessary to determine a reasonable price. Discuss rationale and required updates (attach sales data, catalogues, competitive price list, independent market prices, other data, etc.) |  |  |
(4) Identifies submission of subcontractor cost or pricing data necessary to determine a reasonable price. (Even if HCA waived the submission for prime contractor) |  |  |
(5) Price analysis and objective adjustments resulting from requirement changes |  |  |
(6) Significant differences between objective and negotiated amounts | NA |  |
(7) Use of advisory information and report (s) to support the objective, including significant differences, objective, and final negotiated agreement. |  |  |
b. Discuss analysis and support for proposed, objective and (PNM) negotiated positions |  |  |
c. Identify proposal of record used to baseline the objective. |  | NA |
d. When receiving certified cost and pricing data, a statement of the extent to which the contracting officer relied on contractor provided data except where specifically identified (including agreed to cut-off dates) | NA |  |
e. Actions exceeding TINA threshold, the contracting officer must search the Contract Business Analysis Repository (CBAR) and document the results of CBAR search. |  |  |
f. When performing cost analysis, major cost element summary with subparagraph index for proposed, objective and considered negotiated amounts (including direct and indirect costs for labor, materials,) |  |  |
g. Discussions of cost analysis performed for each major cost element for contractor proposed, government objective and considered negotiated positions in the following areas: |  |  |
(1) Summary breakout of major cost items |  |  |
(A) Labor hours by rate category |  |  |
(B) Identify and discuss indirect rate (s) |  |  |
(C) Materials and other costs by category |  |  |
(D) Subcontractor cost or pricing data |  |  |
1. Requirement, availability, adequacy of and reliance on subcontractor cost or pricing data |  | NA |
2. Sole source or competitive |  | NA |
3. Extent and adequacy of the prime's review |  | NA |
4. Why the contracting officer did not receive certified cost or pricing data when required (attach waiver or describe exemption) |  | NA |
5. Why the contracting officer received certified cost or pricing data when not required |  | NA |
(E) Basis or estimating method used |  |  |
(F) Explanation of contractor data not relied on and reason for using other than contractor's data, identify data used to develop the government's position |  |  |
(G) Rationale, sources, and currency of the data used to set the objective (include modification change determined to be noncommercial where originally determined commercial) |  | NA |
(H) Significant differences between the objective and negotiated amounts | NA |  |
(I) Use of advisory reports supporting the objective, including significant differences between them, the objective, and the final negotiated agreement |  |  |
(J) For undefinitized contract actions: actual costs to date, % of completion, trends and, as applicable, the contractor's estimate to complete |  |  |
(2) With incentive arrangements, describe the basis for share ratio (s) and ceiling price (s) |  | NA |
(3) Profit (Fee). Explain how the contracting officer developed the objective |  |  |
(A) If using WGM, state assigned weights and provide reasoning when weights are below or above normal. (DD 1547 Attached to the PNM) |  | NA |
(B) If not using WGM, explain why and how the contracting officer developed the profit objective |  | NA |
(C) List profit or fee rate (s) negotiated. If the contracting officer did not achieve WGM profit objectives during negotiations, explain why and support profit or fee rate negotiated | NA |  |
g. Summarize and include a definitive statement on why the negotiated price is fair and reasonable. (Address the 25% limitation on price increases (DFARS 217.7505) | NA |  |
h. Description of the basis of any escalation rates used for adjusting historical prices and for forecasting option year prices. See DoD Contract Pricing Reference Guide, Volume 2 Quantitative Techniques, Chapter 1 Using Price Index Numbers for potential sources of information, calculating adjustments, and other relevant topics. |  |  |
i. Summarize and include a definitive statement on why the negotiated price is fair and reasonable. (Address the 25% limit on price increases (DFARS 217.7505) |  |  |
6. Advisory reports and key documents |  |  |
a. List government advisory reports (audit, pricing, technical, should cost, etc. Include title, report number and date.) |  |  |
(1) Explain use of informal field support instead of formal report (s) |  |  |
(2) Explain basis for any field reports required but not received |  | NA |
b. Give status, explanation, and disposition of deficiencies on the following contractor systems that affect negotiations |  |  |
(1) Accounting system (include adequacy of disclosure statement and compliance with cost accounting standards) |  | NA |
(2) Purchasing system |  | NA |
(3) Compensation system |  | NA |
(4) Estimating system |  | NA |
(5) Any other business systems |  |  |
c. List and identify contractor-provided data other than cost or pricing data and cost or pricing data. Identify certificate of current cost or pricing data, if provided. | NA |  |
7. Signatures |  |  |
Include signatures of the author of the PNM, contracting officer and (as applicable) approval authority |  |  |
8. Attachments |  |  |
a. DD Form 1547 - Weighted Guidelines |  |  |
b. DD Form 1861 - Facilities Capital Cost of Money (objective only) |  |  |
c. Other attachments identified in the PNM |  |  |