Fld Name / |
Instruction |
Date |
In the first blank provided enter the day of the agreement. In the second blank provided enter the month of the agreement. In the third blank enter the last two (2) digits of the year of the agreement. |
Contractor’s Name |
Enter the complete name of the contractor responsible for oversight of the construction project in the blank provided. |
Name of Subcontractor |
Enter the complete name and address of the subcontractor hired by the contractor to perform construction activities under the construction contract in the blank provided. |
Agreement Clause – Contractor and Owner
Fld Name / |
Instruction |
Construction Contract or Equipment Contract Date |
In the first blank provided enter the month and day of the construction or equipment contract. In the second blank enter the last two (2) digits of the year of construction or equipment contract. |
Owner’s Name |
Enter the complete name of the telecommunications company in the blank provided. |
Construction Activities |
Enter a brief description of the construction activities to be performed by the contractor under the construction contact in the blanks provided. |
RUS Designation |
Enter the abbreviation for the state where the telecommunications company is located. Enter the 3 digit RUS identification code that is assigned to the telecommunications company. Example: AL 506. |
Section I.
Subcontractor’s Obligations
Fld Name / |
Instruction |
Construction Activities of the Subcontractor |
Enter a description of the construction activities that will be the responsibility of the subcontractor under the construction contract. Example: Copper Cable and Fiber Optic Splicing, Directional Boring, etc. |
Section 4
Payment of Subcontractor
Fld Name / |
Instruction |
Subcontractor Payment |
In the blanks provided spell out and then enter the numerical dollar amount indicating the total amount that the contractor intends to pay the subcontractor for construction activities performed under the construction contract. Do not use commas in the numerical dollar amount. Example: One Hundred Thousand Dollars and No Cents, $ 100000.00. |
Subcontractor Payment Schedule |
Enter the numerical dollar amount that the contractor will pay the subcontractor for completion of the subcontractor’s assigned construction activities in the blanks provided. Do not use commas in the dollar amount. Example: Copper Cable Splicing – 10000.00; Fiber Optic Cable Splicing – 20000.00; etc. |
Fld Name / |
Instruction |
Contractor |
Enter the signature of the contractor or the signature of the contractor's representative in the blank provided. |
Contractor’s Title |
Enter the title of the person who signed for the contractor in the blank provided. |
Subcontractor |
Enter the signature of the subcontractor or the signature of the subcontractor's representative in the blank provided. |
Title of Subcontractor |
Enter the title of the person who signed for the subcontractor in the blank provided. |
Fld Name / |
Instruction |
Seal – Owner |
Affix the seal of the telecommunications company in the area provided when required. |
Owner |
Enter the name of the of the telecommunications company in the blank provided. |
President Owner |
Enter the signature of the President of the telecommunications company or the signature of the telecommunications company’s representative in the blank provided. |
Date – Owner |
Enter the month, day and year (4 digits) the telecommunications company signs the form. |
Seal – Surety Company |
Affix the seal of the Surety (bonding) company in the area provided when required |
Surety Company |
Enter the name of the of the Surety (bonding) company in the blank provided. |
Surety Company Signature |
Enter the signature of the Surety (bonding) company’s representative in the blank provided. |
Date – Surety Company |
Enter the month, day and year (4 digits) the Surety (bonding) company signs the form. |