Blank Statement of Intent

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Blank Statement of Intent

Uploaded by

ruben7750

We take content rights seriously. If you suspect this is your content, claim it here.

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STATEMENT OF INTENT Sale/Lot #________________________

ACKNOWLEDGEMENT:
The Bidder represents and warrants that the ultimate destination, use, and disposition of the property
shall be in accordance with the Statement of Intent and/or Statement of Acknowledgement as submitted
and approved by the Contracting Officer. Any unauthorized disposition of the property by a sub-purchaser
or sub-receiver of the property shall be the responsibility of such sub-purchaser or sub-receiver and,
where at fault, of the original buyer from the United States. The trade control actions required will be
applied to all items included in the original sale. Resale breakdowns of such sales will still be subject to
the same control requirements applicable to the original sale. The Standard Form 114C, June 1997 and
the Special Requirements and Conditions are included by reference.

Misuse of these items to compromise national security and/or to create or disseminate biological warfare
agents is illegal. Further, the re-sale and/or exportation of certain technological items to countries subject
to trade security controls is prohibited. You may be subject to prosecution if these items are used for
illegal activity. Reference Online Special Terms and Conditions “Export Restriction Notice.”

BIDDER INFORMATION
a. NAME OF BIDDER:
_____________________________________________________________
b. TAX IDENTIFICATION NUMBER (TIN):
_____________________________________________________________
c. BIDDER’S ADDRESS:
_____________________________________________________________
d. TELEPHONE NUMBER
_____________________________________________________________
e. PLEASE LIST BUSINESS OR OTHER NAMES USED BY THE PRINCIPAL BIDDER:

NATURE OF BUSINESS:
(1) BROKER, MARKETER, RETAILER or WHOLESALER
(2) TREATMENT, STORAGE AND/OR DISPOSAL FACILITY
(3) OTHER (Specify)

SPECIFIC USAGE:
AS A PURCHASER, I WILL:

(1) RESELL ITEM(S):______________________________________________________________

(2) USE ITEM AS INTENDED:_______________________________________________________
(3) SCRAP ITEM(S) FOR RECOVERY OF CONTENTS:__________________________________
(4) RE-REFINE/REPROCESS ITEM (S) _______________________________________________
(5) OTHER (Specify Item)________________________________________________________

RESALE OF ITEM(S):
If items are resold and when requested by the Contracting Officer to furnish information regarding the
disposition made of the property awarded to the Purchaser, the Purchaser agrees to furnish the
requested information within the specified timeframe stated by the regional Sales Contracting Officer.

CERTIFICATION:
I CERTIFY THAT ALL OF THE INFORMATION GIVEN IN THIS STATEMENT IS TRUE AND CORRECT.
I UNDERSTAND THAT THIS STATEMENT IS INCORPORATED BY REFERENCE INTO ANY
RESULTING CONTRACT OF SALE WITH THE U.S. GOVERNMENT.

____________________________________________________________________________________
Signature of Official Bidder Date of Signing