SF 1440 Application For Partial Payment

OMB Control Number: 9000-0012
Expiration Date: 2/28/2017

APPLICATION FOR PARTIAL PAYMENT

Paperwork Reduction Act Statement - This information collection meets the requirements of 44 USC § 3507, as amended by section 2 of the Paperwork Reduction Act of 1995. You
do not need to answer these questions unless we display a valid Office of Management and Budget (OMB) control number. The OMB control number for this collection is 9000-0012.
We estimate that it will take 2.5 hours to read the instructions, gather the facts, and answer the questions. Send only comments relating to our time estimate, including suggestions for
reducing this burden, or any other aspects of this collection of information to: U.S. General Services Administration, Regulatory Secretariat Division (M1V1CB), 1800 F Street, NW,
Washington, DC 20405.

For use by Prime Contractor or Subcontractor under contracts terminated for the convenience of the Government

THIS APPLICATION APPLIES TO (Check one)
A PRIME CONTRACT WITH
SUBCONTRACT OR
THE GOVERNMENT
PURCHASE ORDER
SUBCONTRACT OR PURCHASE ORDER NUMBER(S)

APPLICANT

STREET ADDRESS

CONTRACTOR WHO SENT NOTICE OF TERMINATION
NAME
CITY AND STATE (Include ZIP Code)
ADDRESS (Include ZIP Code)
NAME OF GOVERNMENT AGENCY

IF CONTRACTOR HAS GUARANTEED LOANS OR HAS ASSIGNED
MONEYS DUE UNDER THE CONTRACT, GIVE THE FOLLOWING:

GOVERNMENT PRIME CONTRACT NUMBER

NAME AND ADDRESS OF FINANCING INSTITUTION (Include ZIP Code)

CONTRACTOR'S REFERENCE NUMBER

NAME AND ADDRESS OF GUARANTOR (Include ZIP Code)

EFFECTIVE DATE OF TERMINATION

DATE OF THIS APPLICATION

NAME AND ADDRESS OF ASSIGNEE (Include ZIP Code)

AMOUNT REQUESTED

APPLICATION NUMBER UNDER THIS
TERMINATION

$
SECTION I - STATUS OF CONTRACT OR ORDER AT EFFECTIVE DATE OF TERMINATION
FINISHED
UNFINISHED OR NOT
ON HAND
COMMENCED
PRODUCTS COVERED BY TERMINATED
PREVIOUSLY PAYMENT TO BE INCLUDED IN
TO BE
NOT TO BE
RECEIVED
SHIPPED AND
CONTRACT OR PURCHASE ORDER
THIS
INVOICED

(a)

(b)

THROUGH
INVOICING
(c)

APPLICATION
(d)

COMPLETED

COMPLETED

(e)

(f)

TOTAL
COVERED BY
CONTRACT
OR ORDER
(g)

QUANTITY

$
QUANTITY

$
QUANTITY

$
SECTION II - APPLICANT'S OWN TERMINATION CHARGES
(Exclusive of its Subcontractors' Charges)
ITEM
ACCEPTABLE FURNISHED PRODUCT (at contract price)
WORK-IN-PROCESS
RAW MATERIALS, PURCHASED PARTS, AND SUPPLIES
GENERAL AND ADMINISTRATIVE EXPENSES
TOTAL (Sum of lines 1, 2, 3, and 4)
SPECIAL TOOLING AND SPECIAL TEST EQUIPMENT
OTHER COSTS
SETTLEMENT EXPENSES
TOTAL (Sum of lines 5, 6, 7, and 8)
10. SUBCONTRACTOR SETTLEMENTS APPROVED BY CONTRACTING OFFICER OR SETTLED
UNDER A DELEGATION OF AUTHORITY AND PAID BY APPLICANT
11. AMOUNT RECEIVED
(a) UNLIQUIDATED PARTIAL, PROGRESS, AND ADVANCE PAYMENTS RECEIVED
(b) DISPOSAL AND OTHER CREDITS
(c) TOTAL (Sum of lines a and b)
(d) AMOUNT OF PARTIAL PAYMENT REQUESTED
(e) TOTAL (Sum of lines c and d)

NUMBER

1.
2.
3.
4.
5.
6.
7.
8.
9.

AUTHORIZED FOR LOCAL REPRODUCTION
Previous edition is usable

SETTLEMENT
ATTACHED
PREVIOUSLY SUBMITTED
CHARGES AS LISTED IN SETTLEMENT PROPOSAL

$

$

$
$
$

$
STANDARD FORM 1440 (REV. 1/1995)
Prescribed by GSA-FAR (48 CFR) 53.249(a)(7)

SECTION III - AGREEMENT OF APPLICANT
IN CONSIDERATION OF PARTIAL PAYMENT THAT MAY BE MADE, THE APPLICANT AGREES AS FOLLOWS:
(a) Repayment of Excess. If any partial payment made to the Contractor is in excess of the amount finally determined to be due on its termination settlement proposal or claim, the
Contractor shall repay the excess to the Government upon demand together with interest at the rate established by the Secretary of the Treasury under 50 U.S.C. (app.) 1215(b)(2).
Interest shall be computed for the period from the date of the excess payment to the date the excess is repaid. Interest shall not be charged however, for any (1) excess payment
due to a reduction in the Contractor's proposal or claim because of retention or other disposition of termination inventory, until 10 days after the date of the retention or disposition,
or any later date determined by the Contracting Officer because of the circumstances, or for (2) overpayment under cost-reimbursement research and development contracts
(without profit or fee to the Contractor) if the overpayments are repaid to the Government within 30 days after demand.
(b) Prompt Settlement of Proposal. The applicant will make every effort to expedite final settlement of the termination settlement proposal and any proposals of its subcontractors.
(c) Disposal and Retention of Inventory. The applicant shall, within 10 days, notify the Contracting Officer whenever the proceeds received from the disposal of termination
inventory, when added to the cost or agreed value of inventory retained by the applicant, exceeds the amount of its charges (Section II, Line 9) and the amount of such credits has
not been included on Section II, Line b (Disposal and Other Credits).

SECTION IV - CERTIFICATE OF APPLICANT
I certify that the amount of charges (exclusive of subcontractors' charges) due as of the date of this application and allocable to the terminated portion of contract
number

dated

with

; that, to the best of my knowledge,

, is not less than $

(From Section II, Line 9)

the amounts received are set forth above; and that I have not assigned any moneys payable under this contract, except as set forth above.
NAME OF APPLICANT

BY (Signature of authorized official)

TITLE

DATE

SECTION V - RECOMMENDATION OF FIRST REVIEWING CONTRACTOR
The undersigned states that it has examined this application and has considered the applicant's general reputation. It has no reason to doubt the accuracy of the
information contained in this application or that amount certified by the applicant as due will constitute a proper charge to be included in the undersigned's termination
settlement proposal against
It recommends that the requested partial payment be made.
The undersigned agrees that it will promptly pay over to the applicant or credit against amounts owing from the applicant any amount received for the benefit of the
applicant under this application, and that it will repay to the Government on demand any amount not so paid or credited.
NAME OF CONTRACTOR

BY (Signature of authorized official)

TITLE

DATE

SECTION VI - RECOMMENDATION OF OTHER REVIEWING CONTRACTORS
Each of the undersigned states that it has no reason to doubt that the amount of the partial payment requested, and recommended above is due the applicant will
constitute a proper charge in the termination settlement proposal of the undersigned.
Each of the undersigned agrees that it will promptly pay over to its immediate subcontractor or credit against amounts owing from such subcontractor any amount
received for the benefit of the applicant under this application, and that it will repay to the Government on demand any amount not so paid or credited.

CONTRACTOR

DATE

IDENTIFICATION OF
YOUR CONTRACT

SIGNATURE OF OFFICER, PARTNER,
OR OWNER

1

2

3
(Where the space provided for any information is insufficient, continue on a separate sheet.)
STANDARD FORM 1440 (REV. 1/1995) BACK