PERSONAL SERVICES CONTRACTING ACTION



PERSONAL SERVICES CONTRACTING ACTION

|1. Name (Family/surname, Given name/s) and address |2. ID Number       |3. Contract Number |4. Ethics Code |

|      | |      | |

| |Citizenship:       | |N |

| | | |C |

| |Green Card Holder Yes No | |P |

|5. Country of Performance |6. Period of Performance |7. Effective Date |8. Contract Type |

|      |      |      |U.S. CCN/FSN TCN |

|9. Benefits Plan |10. Obligation Amount (this action) |11. Total Estimated Contract Cost |

|LCP U.S. (LH) U.S. (Offshore) TCN |      |      |

|12. Supervising Officer |13. Contracting Office (Name, Office Symbol, Address) |14. Request Number |

|      |      |      |

|15. Cognizant Technical Office (Name, Office Symbol, Address) |16. Administered By (If other than Contracting Office) |

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|17 Position Title (Series Code and Position Number) |

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|18. Name of Agency, Location of Employing Office |

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|19. PREVIOUS POSITION: (FSN/TCN) |20. CURRENT POSITION: (For U.S.) |

|Pay Plan Grade Step Salary Pay|Starting Salary Daily Rate Hourly Rate |

|Basis |                  |

|                             | |

|21. Work Hours/Schedule       |

|22. Duty Station       |

|23. Accounting & Classification Codes: |

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|24. Payment will be made by (Name, Office Symbol, Address) |NOTE: See Page 2 of 2 for all PSC Contracts |

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|25. Remarks |

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|This Contract consists of this Cover Page, the Schedule, General Provisions and FAR Clauses. |

|26. Signature of Contractor |27. By (Signature of Contracting Officer) |

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|28. Typed or Printed Name |29. Typed or Printed Name |

|      |      |

|30. Date |31. Date |

|      |      |

The United States of America, herein called the Government, represented by the Contracting Officer executing this contract, and the contractor agree that the Contractor shall perform all the services set forth in the attached Schedule, for the consideration stated herein. The rights and obligations of the parties to this contract shall be subject to and governed by the schedule and the General Provisions. To the extent of any inconsistency between the Schedule or the General Provisions and any specifications or other provisions which are made a part of this contract, by reference or otherwise, the Schedule and the General Provisions shall control. To the extent of any inconsistency between the Schedule and the General Provisions, the Schedule shall control.

SPECIAL NOTE:

For U.S. Citizens, as an employee for purposes of Section 636(a)(3) of the Foreign Assistance Act of 1961, as amended (22 USC 2396(a)(3)), the Contractor is generally an employee of the United States for purposes of laws other than those administered by the Office of Personnel Management (i.e., Title 5, United States Code). This includes being an employee of the United States for the purposes of Title 26, United States Code, which subjects the Contractor to withholding for both FICA and Federal Income Tax, and precludes the Contractor from receiving the federal earned income tax exclusion of 26 USC Section 911.

For U.S. Citizens:

PRIVACY ACT STATEMENT

This information is provided under Public Law 93-579 (Privacy Act of 1974), December 21, 1974, for individuals who complete this form.

The Executive Office of the President, Office of Management and Budget has required that all departments and agencies comply with the reporting requirements of Section 6041 of the Internal Revenue Code. Section 6041 states that all departments and agencies making payments totaling $600 or more in one year to a recipient for services provided must be reported to the Internal Revenue Service (IRS). The SSN and all financial numbers will be disclosed to U.S. Agency for international Development (USAID) payroll office personnel and personnel in the Department of the Treasury, Division of Disbursements. USAID will use this SSN to complete Form W-2 of the Code on employee compensation. Disclosure by the personal services contractor of the SSN is necessary to obtain the services, benefits or processes provided by this contract. Disclosure of the SSN may be made outside USAID (a) under any applicable routine use listed in USAID’s Notice for implementing the Privacy Act as published in the Federal Register or (b) when disclosure by virtue of a contract being a public document after signatures is authorized under the Freedom of Information Act.

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