Form Approved

MATERIAL INSPECTION AND RECEIVING REPORT OMB No. 0704-0248

Public reporting burden for this collection of information is estimated to average 30 minutes per response, including the time for reviewing instructions, searching existing data sources,
gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspects of this
collection of information, including suggestions for reducing this burden, to Department of Defense, Washington Headquarters Services, Directorate for Information Operations and
Reports (0704-0248), 1215 Jefferson Davis Highway, Suite 1204, Arlington, VA 22202-4302. Respondents should be aware that notwithstanding any other provision of law, no person
shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number.
PLEASE DO NOT RETURN YOUR COMPLETED FORM TO THE ABOVE ADDRESS.
SEND THIS FORM IN ACCORDANCE WITH THE INSTRUCTIONS CONTAINED IN THE DFARS, APPENDIX F-401.
1. PROCUREMENT INSTRUMENT IDENTIFICATION
(CONTRACT) NO. (ORDER) NO. 6. INVOICE NO./DATE 7. PAGE OF 8. ACCEPTANCE POINT

xxxx-xxx-xxxxx 0001 002 12 FEB 2011 1 1 D

2. SHIPMENT NO. 3. DATE SHIPPED 4. B/L N/A 5. DISCOUNT TERMS

N/A
TCN

9. PRIME CONTRACTOR COD OEUA6 10. ADMINISTERED BY CODE W911S0

PRIMES INFORMATION COGIZANT AGENCY'S INFORMATION

11. SHIPPED FROM (if other than 9) COD FOB: 12. PAYMENT WILL BE MADE BY CODE HQ0105
PRIMES INFORMATION DFAS INFORMATION - Location to fax invoice

13. SHIPPED TO W26RIP 14. MARKED FOR CODE

15. 16. STOCK/PART NO. DES 17. QUANTITY 18. 19. 20.
ITEM (INDICATE NUMBER OF SHIPPING CONTAINERS - TYPE OF SHIP/REC'D* UNIT UNIT PRICE AMOUNT
NO. CONTAINER - CONTAINER NUMBER.)

0001AA each 1.00 $ -

0001AC each 1.00 $ -

Sub- Total $ -

Total: $ -
21. CONTRACT QUALITY ASSURANCE 22. RECEIVER'S USE
A. ORIGIN B. DESTINATION

CQA ACCEPTANCE of listed items has CQA ACCEPTANCE of listed items has Quantities shown in column 17 were received in
X
been made by me or under my supervision and X
been made by me or under my supervision and apparent good condition except as noted.
they conform to contract, except as noted herein they conform to contract, except as noted herein
or on supporting documents. or on supporting documents. DATE COR Signature
SIGNATURE OF AUTHORIZED
DATE RECEIVED GOVERNMENT REPRESENTATIVE
DATE COR Signature DATE COR Signature TYPED NAME: COR fill in information
SIGNATURE OF AUTHORIZED SIGNATURE OF AUTHORIZED
DATE GOVERNMENT REPRESENTATIVE DATE GOVERNMENT REPRESENTATIVE TITLE: COR fill in information
TYPED NAME: COR fill in informatio TYPED NAME: COR fill in informati MAILING ADDRESS:

TITLE: COR fill in information TITLE: COR fill in information COR fill in information
COR fill in COMMERCIAL
TELEPHONE
MAILING ADDRESS: MAILING ADDRESS: information NUMBER: COR fill in information
COR fill in information
COMMERCIAL COMMERCIAL *if quantity received by the Government is the same as quantity
TELEPHONE TELEPHONE shipped, indicate by check mark, if different, enter actual
NUMBER: COR fill in informatio NUMBER: COR fill in informati quantity received below quantity shipped and encircle.
23. CONTRACTOR USE ONLY
This DD 250 covers the period 02/04/2010 - 01/28/2011 Period of Performance: 02/04/2010 - 01/28/2011

Delivery Order Value: $0.00

Previously $ Invoiced: $0.00

DD Form 250 JAN 90 Previous editions are obsolete 304 254

1991 - 221.405/40002
 This Invoice: $ -

DD FORM 250, AUG 2000 PREVIOUS EDITION IS OBSOLETE

DD Form 250 JAN 90 Previous editions are obsolete 304 254

1991 - 221.405/40002