Get GSA Form 618D 2002-2024

U.S. GSA Form gsa-618d DATE STATEMENT TO BE SUBMITTED WHEN WORK IS PERFORMED PERSONALLY NAME OF SIGNATORY PARTY TITLE OF SIGNATORY PARTY NAME OF FIRM SUBMITTING STATEMENT TYPE OF CONTRACTOR NATURE OF WORK PRIME SUBCONTRACTOR NAME OF BUILDING WHERE WORK WAS DONE LOCATION OF BUILDING City and State CONTRACT NUMBER DESCRIPTION OF WORK As the case requires state all work or list the specific classes of work NAME OF PERSON S PERFORMING WORK CONNECTION WITH THE FIRM I certify that the above information is true that no wages were received for the labor performed that no mechanics or laborers were employed in the prosecution thereof and that the work was done during the period mentioned below. SIGNATURE LAST DATE ON WHICH WORK WAS PERFORMED AT THE SITE Section 1001 of Title 18 of the United States Code Criminal Code and Criminal Procedures shall apply to such statements - 72 Stat. 967 18 U*S*C. 1001 among other things provides that whoever knowingly and willfully makes or uses a document or writing containing any false fictitious or fraudulent statement or entry in any matter within the jurisdiction of any department or agency of the United States shall be fined not more than 10 000 or imprisoned not more than five years or both. INSTRUCTIONS FOR THE SUBMISSION OF STATEMENTS OF WORK PERFORMED PERSONALLY Prime contractors or subcontractors who personally perform the work are required to submit in lieu of weekly statements of compliance and payrolls with respect to the payment of wages pursuant to the Copeland Anti-Kickback regulations a certified statement clearly wing 1 their contractual relationship 2 the scope and dates of the work performed 3 that they received no wages and 3 that no mechanics or laborers were employed in the prosecution of the work. The above form sets forth the wording prescribed for such certified statements. statements should be forwarded to the prime contractor for transmission to the Government contracting officer or his/her designated representative. Statements of prime contractors and subcontractors should be submitted as soon as possible after the last date on which work was performed at the site. To facilitate identification of the project involved prime contractors should provide their subcontractors with the Government contract number as called for on the statement form* necessary information* GENERAL SERVICES ADMINISTRATION GSA FORM REV. SIGNATURE LAST DATE ON WHICH WORK WAS PERFORMED AT THE SITE Section 1001 of Title 18 of the United States Code Criminal Code and Criminal Procedures shall apply to such statements - 72 Stat. 967 18 U*S*C. 1001 among other things provides that whoever knowingly and willfully makes or uses a document or writing containing any false fictitious or fraudulent statement or entry in any matter within the jurisdiction of any department or agency of the United States shall be fined not more than 10 000 or imprisoned not more than five years or both. 967 18 U*S*C. 1001 among other things provides that whoever knowingly and willfully makes or uses a document or writing containing any false fictitious or fraudulent statement or entry in any matter within the jurisdiction of any department or agency of the United States shall be fined not more than 10 000 or imprisoned not more than five years or both. INSTRUCTIONS FOR THE SUBMISSION OF STATEMENTS OF WORK PERFORMED PERSONALLY Prime contractors or subcontractors who personally perform the work are required to submit in lieu of weekly statements of compliance and payrolls with respect to the payment of wages pursuant to the Copeland Anti-Kickback regulations a certified statement clearly wing 1 their contractual relationship 2 the scope and dates of the work performed 3 that they received no wages and 3 that no mechanics or laborers were employed in the prosecution of the work. .