UoM- Unit of Measurement

SDO- Special Disbursing Officer (Executive or Presiding Judge)

For APR
Agency Property Officer = Branch Clerk of Court/ OCC Assnt. COC
Agency Chief Acountant = Presiding Judge/ OCC-COC
Agency Head/ Authorized Signature = Executive Judge (SDO)
Agency Acct. Code = Will be assigned by PS
Agency Control No. = Will be assigned by the Branch

For Acknowledgement Receipt

Please accomplishment 5 (five) copies of this form
1. Original/File Copy- SDO (Executive/Presiding Judge)
2. Certified Copy- Accounting Division, FMO-OCA
3. Certified Copy- Property Division, OAS-OCA
4. Certified Copy- COA-SC
5. File Copy-Court/Branch/OCC

For Inventory Custodian Slip (ICS)

How to Assign ICS No
ICS-Court-Station Code-Year Acquired-Quantity
(Ex. If 5 (five) units of stapler were purchased by MTCC branch, ICS-MTCC-R1-22-18-1 to 5)

For Refund Receipt

Please accomplishment 5 (five) copies of this form
1. Original/File Copy- SDO (Executive/Presiding Judge)
2. Certified Copy- Accounting Division, FMO-OCA
3. Certified Copy- Property Division, OAS-OCA
4. Certified Copy- COA-SC
5. File Copy-Court/Branch/OCC
APR FORM revised March 2007
NAME AND AGENCY ACCT. CODE
ADDRESS OF
REQUESTING
AGENCY/COURT
AGENCY CONTROL NO.
TEL NOS
AGENCY PROCUREMENT REQUEST PS APR No.
To:

(Date Prepared)
PLEASE CHECK (√) APPROPRIATE BOX ON ACTION REQUESTED ON THE ITEMS/LISTED BELOW

[ ] Please issue common-use supplies/materials par Price List No. _________________ dated ____________
Mode of Delivery: [ ] Pick-up (Fast Lane) [ ] Pick-up (Schedule) [ ] Delivery (door-to-door)

In case fund is not sufficient: [ ] Reduce quantity [ ] Bill Us [ ] Charge to utilizatio Deposit, APR No. _______ Date _______

[ ] Please purchase for our agency non-common items. Attached herewith;

[ ] Complete Specifications [ ] Obligation Request (ObR) [ ] Others, pls. specify ___________
[ ] Certificate of Budge Allocations (CBA) [ ] Payment

IMPORTANT! PLEASE SEE THE INSTRUCTIONS/CONDITIONS AT THE BACK HEREOF

Item ITEM AND DESCRIPTION Quantity Unit Unit Price Amount
No.
₱ ₱

Total Amount ₱
NOTE: ALL SIGNATURES MUST BE OVER PRINTED NAME
STOCKS REQUESTED ARE CERTIFIED TO BE WITHIN FUNDS VERIFIED AVAILABLE Approved:
APPROVED PROGRAM:

AGENCY PROPERTY OFFICER AGENCY CHIEF ACCOUNTANT AGENCY HEAD/ AUTHORIZED SIGNATURE

(Bcoc/OCC Asst. BCoC) (Presiding Judge/OCC-CoC) (Executive Judge (SDO)

[ ] FUNDS DEPOSTIED WITH PS [ ] ________________ CHECK No. ______________ IN THE AMOUNT OF

_____________________________________________ (₱ ______________) ENCLOSED
 PURCHASE REQUEST

Court and Station:

Region: P.R. No.: Date:

Stock No. Unit Item with Description/Specification Quantity Unit Cost Total Cost
₱ ₱

Grand Total ₱
Pupose: For Official use of (court station)
This is to certify that the above items are included and are within approved quantity and budget of this court's approved Project
Procurement Management Plan/Annual Procurement Plan for the current year.

Requested by Clerk of Court/Asst. COC (OCC) Procurement Approved by (PJ/APJ/OCC CoC):

Signature over printed name Signature over printed name

The amount ₱ _________________ will be made Fund Release and

available for this request. Approved by SDO (EJ):
Chargeable against MOOE Fund

Signature over printed name

Total Budget for this Semester :

Total Amount for this Procurement :
Balance of Budget for this Semester :

Note: PR submitted to the SDO (EJ) for funding/budget puposes must be supported by the Abstract of Quotation/
Canvass (if there is more than 1 quotation) and Price Quotation Form/s.
 Republic of the Philippines

(Court, Branch and Station)

ABSTRACT OF QUOTATION/ CANVASS

Description of Items Unit Quantity (Supplier #1) (Supplier #2) (Supplier #3) (Supplier #4) (Supplier #5)
Unit Pice Total Price Unit Price Total Price Unit Pice Total Price Unit Pice Total Price Unit Pice Total Price

₱ ₱ ₱ ₱ ₱

Delivery Charge (if applicable)

Grand total

Note : Awarded to
(winning supplier)

Prepared and Checked by: Noted by Clerk of Court

Name Name
Signature Signature

Date Date
 Republic of the Philippines
Judicial Region:
Court :
Station :

ACKNOWLEDGEMENT RECEIPT

Date :

Received from the Executive / Presiding Judge

(Name)

of _____________________________________________________________ the amount of

(Court Station)

(₱ ____________________)
(amount in words)

representing Maintenance and Other Operating Expenses (MOOE) allotment for the period

to
(month) (day) (month) (day) (year)

(___________ semester) of
(1st semester/2nd semester) (Court Station)

Received by:

Name of Officer :
Official Designation :
Court Station
 REQUISITION AND ISSUE SLIP (RIS)

Entity Name : Supreme Court of the Philippines

Court and Branch No. :

Station RIS No :
Requisition Stock Available? Issue
Stock No. Unit Description/Item Qnty Yes No Qnty Remarks

Purpose: For day-to-day operation of the court

Requested by: Approved by: Received by:

Signature:
Printed Name:
Designation: CoC/OIC CoC/OIC PJ/APJ/OCC CoC CoC/OIC/Asst CoC-OCC
Date:
 INVENTORY CUSTODIAN SLIP (ICS)

Entity Name : Supreme Court of the Philippines

Court, Branch, Station :
Fund Cluster : Regular Agency Fund

Amount Estimated
Qty Unit Description/Item Issued ICS No.
Unit Cost Total Cost Useful Life

Received from EJ/PJ/APJ Received by OCC/OIC:

Signature over Printed Name Signature over Printed Name

Date Date
* How to assign ICS No.
ICS-Court-Region-Station ID-Year Acquired-Chronologically assigned No. for every type/kind of Item Procured-Quantity

EX. ICS-RTC-R1-2-18-1 to 5
ICS-RTC Court
R1 Region
2 Station ID ([Please refer to "Station ID" file)
18 Year acquired (2018)
1 to 5 Purchased 5 units

Court: RTC, MeTC, MTCC, MTC, MCTC, SDC or SCC

Region: R + Region Number ex. R1,R2,NCR
Station Code: Each branch and OCC has an assigned Station ID
Year Acquired : only the last two (2) digit of the yearthe property was acquired should be reflected. Ex. 2018 = 18
Chronologically Assigned Number for Every Type/Kind of Item Procured: Starting with number 1,
 Republic of the Philippines

(Court, Branch and Station)

PURCHASE ORDER
(Job Order)
To P.O. No. :
P.O. Date :

(Name & Address of Winning Supplier/Contractor) Mode of Procurement:

Tel No. :
Fax No. :

Sir/Madam:
Please furnish this court/office the following articles subject to the terms and conditions contained herein.

Place of Delivery: Payment Term:

(Court, Station, Branch)
Period of Delivery Period of Repair WITHIN _______ DAYS AFTER COMPLETION OF
DELIVERY AND INSPECTION
Within _________ calendar days from receipt hereof.

Warranty (in case of repair) : _____________________________________

No. Stock No. Unit ITEMS (with DESCRIPTION/SPECIFICATION) QTY Unit Price Amount

Total Amount in Words:

Purpose: For official use of

(Court, Branch and Station)

In case of failure to make full delivery within the period specified above, a penalty of one tenth (1/10) of one percent (1%)
of the cost of the undelivered portion for every day of delay shall be imposed.

Conforme: Very truly yours,

Signature over Printed Name od Supplier/Contractor Signature over Printed Name

Clerk of Court
Date
 Republic of the Philippines
Supreme Court

PRE-INSPECTION REPORT

Hall of Justice : ____________________________________

Court, Branch, Station : ____________________________________

Findings :

Inspected by Maintenance Head : Noted by EJ/PJ/Clerk of Court :

Signature over Printed Name Signature over Printed Name

Date : Date :

POST INSPECTION REPORT

Purchase/ Job Order No. : Invoice No. :

Amount of PO/JO Date :
Date
Name of supplier/contractor :

Findings :

Inspected by Maintenance Head : Noted by EJ/PJ/Clerk of Court :

Signature over Printed Name Signature over Printed Name

Date : Date :
 Republic of the Philippines
Judicial Region:
Court :
Station :

REFUND RECEIPT

Date :

Received from Court/Branch/OCC-Clerk of Court/Judge :

(Name)

of _____________________________________________________________ the amount of

(Court Station)

(₱ ____________________)
(amount in words)

representing the unspent/excess balance of Maintenance and Other Operating Expenses

(MOOE) allotted to
(month) (day) (month) (day) (year)

(___________ semester) of
(1st semester/2nd semester) (Court Station)

Received by:

Name of Officer :
Official Designation :
Court Station
 REPORT OF SUPPLIES AND MATERIALS ISSUED

Court, Branch, Station

Court Branch :
P.O. No.: Date:
To be filled up by the BCoC/OCC To be filled up in the Accounting Unit

RIS ITEMS PROCURRED Qty.

UoM Unit Cost Amount
No. (To whom issued) Issued

Total Issued
Recapitulation Recapitulation
Unit Cost Total Cost UACS Object Code
COMPLETE
Amounting to ₱
(Total Amount in the P.O.)

I hereby certify to the correctness of the above information Posted by/ Date
 Accounting Clerk

Clerk of Court

Date
 PROJECT PROCUREMENT MANAGEMENT PLAN FORM FOR
LOWER COURTS

Judicial Region Bldg. name and No. Landline

Contact Nos.
Court Street Mobile
Station Barangay/Zone
Caseload City/Municipality Email address
Branch Province
Special Court Designation Name of EJ/PJ/APJ
(e.g. Family, drug, commercial court)
A-1 Procurement Through PS-DBM
A. Basic Office Supplies UOM Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov
1 Correction Tape Piece
2 Carbon Film, Legal size Box
3 Envelope Documentary (500pcs/Box) Box
4 Envelope , Mailing (500pcs/Box) Box
5 Fastener, Metal Box
6 Folder, Legal size (100pcs/Pack) Pack
7 Glue Jar
8 Paper, Multi-purpose, 216mm x 330mm Ream
9 Paper Clip, Jumbo Box
10 Paper, Ruled pad Pad
11 Pen, Sign, gel type Piece
12 Pen, Marking, permanent Piece
13 Pencil, Lead, with eraser (12Pcs/Box) Box
14 Record Book Piece
15 Rubber band Box
16 Staple wire, copper Box
17 Tape, Transparent Roll
18 Twine, plastic Roll
19 Stamp Pad # 2 Pad
20 Stamp Pad ink Bottle
21 Cutter knife Piece
22 Cutter Blade Unit
23 Scissor Unit
24 Staple Wire Remover Unit
Dec Total
B. Small Office Device UOM Quantity C. Consumables (Printers and Fax) D. Other Supplies Quantity
1 Stapler, Ordinary Unit Brand Model UOM Quantity 1 Official Receipt (General Form)
2 Puncher Unit LX300 Cart 2 Official Receipt (ePayment)
3 Stapler, Big Unit FX2180 Cart 250pp
Civil Docket Book
4 Receiving Machine Unit 1 EPSON LQ300 Cart 3 500pp
Numbering 6 Digits Unit FX2175 Cart 250pp
5 4 Criminal Docket Book
Machine 8 Digits Unit LQ310 Cart 500pp
6 Dry Seal Unit TN 2060 Cart 5 Fiduciary Cash Book 200pp
7 Gavel and Mallet Unit DR3290 Drumkit G.F.
2 Brother
8 Emergency Light Unit TN3350 Cart 6 Judiciary Cash Book J.D.F.
9 Dater Unit TN2380/2060 Cart S.F.
10 Calculator, Solar Unit ML 4050N Cart 7 Bundy Card, Foldcote
11 Calculator w/ paper tape Unit 3 Samsung ML 2550 Cart 8 Catalog Card w/hole
12 Flash Drive/USB Unit MLT D1015 Cart Indoor
9 Philippine Flag
13 Digital Voice Recorder set Unit CF 280XC Cart Outdoor
14 External Hard Drive Unit P110635A Cart 10 Supreme Court Flag
Q7551A Cart 3x5
4 HP
26A Cart 11 Index Card 4x6
3005 Cart 5x8
Items needed but not included in the form 1020 Cart 12 Ink, Steno
Qnty. Item PG40 Cart S
5 Canon LBP3460 Cart M
13 Judicial Gown
JX210P Cart L
Ribbon Roll XL
6 Barcode
Sticker Pad 14 Thermal Paper
BK Brother LC57 15 Stenotype Pads
7 Fax Brother 878 16 Calculator Ribbon
Canon LBP 3460 17 Tally Ribbon (T6218)
18 Tally, Dascom Ribbon (1125)
19 Steel Belt, Horii 255
20 Detainee's Notebook
21 Rewritable DVD
` 22 Registry Return Receipt
 A-2 Bidding/Shopping
A. Basic Office Supplies UOM Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov
1 Expediente Cover (250sheets/Pack) Pack
2 Stitching Needle Piece
3 Thread, Cotton Roll
4 Ballpen, Blue (50pcs/Box) Box
5 Onion Skin, Paper, Legal Ream
` 6 Mimeograph, Paper, Legal Ream
7 Ribbon for Manual Typewriter Roll
Dec Total
E. Furniture (Pls. refer to attached technical specification) UOM Quantity G. Law Books
1 Senior Executive Table (For Judge) Unit Title/Edition/Year Author
2 Senior Executive Chair (For Judge) Unit 1
3 Junior Executive Table (For CoC) Unit 2
4 Junior Executive Chair (For CoC) Unit 3
5 Clerical Table Unit 4
6 Clerical Chair w/o armrest Unit 5
7 Clerical Chair w/ armrest Unit 6
8 Computer Table Unit 7
9 Long Table Unit 8
10 Gang Chair (3 seaters) Unit 9
11 Visitors Chair Unit 10
12 Sofa Unit 11
13 Filing Cabinet (4 drawers) Unit 12
14 Filing Cabinet (2 drawers) Unit 13
15 Card Catalog Cabinet Unit 14
16 Index Card Cabinet Unit 15
17 Typing Table Unit 16
18 Monoblock Chair Unit 17
19 Stand Fan Unit 18
20 Orbit Fan Unit 19
21 Wall Fan Unit 20
22 Storage Cabinet Unit
23 Vault Unit Prepared By:
24 Book shelf Unit Name and Signature
25 Open Type Steel Rack Unit Position:
26 Safe File Unit
Date:
F. Equipment UOM Quantity
1 Manual Typewriter Unit Reviewed by:
2 Biometric Unit Name and Signature
3 Fax Machine Unit Position:
4 Aircon Unit
5 Steno Machine Unit Date:
6 Duplo Machine Unit
7 Computer Unit
8 Printer Unit
Author

Technical Specification
Vertical Filing Cabinet with Safety Vault
two (2) keys; powder coated finished with
Steel vertical filing cabinet with top safet
vault; top safety vault- inside door with one
(1) dial and one(1) key; outside door with
one (1) key; centralized locking system for
the three (3) drawers; powder coated
finished with anti-rust protection; gauge -
#20; size - at least 52"H x 18"W x 24"D; color
- gray. First drawer, insulated with perlite to
safeguard records and valuables from 2 to 3
hours of fire. D = 22"; W = 15½" ; H = 10"
more or less. Distance from case to vault, at
least 3½".
Steel vertical filing cabinet with two (2) drawers;
powder coated finished with anti rust protection,
Technical Specification
Open Type Steel Rack
Open type steel rack with five (5) adjustable steel
shelf; heavy duty; 100 kg. capacity/shelf;
dimension- at least L=900cm ; W=45 cm and
H=180cm
Technical Specification
Vertical Filing Cabinet with four (4) Drawers
Steel Vertical Cabinet with Four (4)
Drawers; centralized locking system with
anti-rust protection; gauge- #20, size- at
least 52"H x 18"W x 24"D; color- light
gray.
Technical Specification
Vertical Filing Cabinet with Two (2) Drawers
centralized locking system with two (2) keys,
gauge - #20, size - at least 29"H x 18"W x 24"D;
color - light gray
Technical Specification
Index Card Cabinet
Steel Storage Cabinet
Steel Storage Cabinet; two (2) steel
swing door type; five (5) adjustable
shelves; powder coated finish with anti-
rust protection; gauge - #20; size - at
least 72"H x 35 ½"W x 18"D; color - light
gray
Technical Specification
Safe Vault
single door; all fireproof; made from heavy duty
Cold Rolled Sheet (CRS); GAUGE- #18 body and
#14 door; insulated with perlite with 3 to 4 hours
fire resistant; with imported combination lock
provided with one dial and one key; painted with
powder coated- finshed with anti-rust protection;
color- dark gray; outside dimension- at least 24"H
x 17"W x 19 ½"D; inside dimension- at least
16½"H x 12"W x 12"D.

Steel index card cabinet; size - 5"X8"; twelve (12)

drawers; made from heavy duty Cold Rolled Sheet Technical Specification
(CRS); Gauge- #20; centralized lovking mechanism; Catalog Cabinet
with stand base; powder coated-finished with anti-
rust protection.
Steel index card cabinet; sixe-3"x5"; twenty-four
(24) drawers made from heavy duty Cold Rolled
Sheet (CRS); Gauge- #20; centralized lovking
mechanism; with stand base; powder coated-
finished with anti-rust protection.
Senior Executive Table (for Judge)
Specifications :
• 50 mm thick
• wooden laminated executive table with built in writing pad, leatherette,
with two (2) grommet holes on table top
• with center drawer and three (3) side drawers on one side and one (1) cabinet on other side,
with central locking system
• color: mahogany
• wooden laminated panel legs
• at least with a dimension of 160cm W x 80cm D x 76cm H

Junior Executive Table (for CoC/BCoC)

Specifications :
• 30 mm thick postform with 2mm edgeband on sides
• Medium Density Fiber Board (MDF) high pressure laminated table top,
with one (1) grommet hole on table top, scratchproof
• color: beige
• with beige steel leg powder coated finish
• metal gauge 0.7 mm before coating
• at least with dimension of 140cm W x 70cm D x 74cm H

Clerical Table
Specifications:
• 30mm postform with 2mm edgeband on sides
• Medium Density Fiber (MDF) Board, high pressure laminated table top,
with one (1) grommet hole on table top, scartchproof
• color: beige
• with beige steel leg powder coated finish
• with one (1) steel mobile drawer that has two (2) small drawers and one (1) file drawer,
with central locking system with keys
• metal gauge 0.7mm before coating
• at least with a dimension of 120cm W x 70cm D x 74cm H

Computer Table
Specifications:
• wood gain finish cherry
• tower tyoe computer table, with CPU holder
• with twin caster and with caster lock
• over -all metal frame in 1.2mm thick, gray metal frame
• at least with an over all dimension of 70cm L x 70cm W x 126cm H

Typing Table
Specifications:
• 30mm postform with 2mm edgehand on sides
• Medium Density Fiber (MDF) Board table top, high pressure laminated table top,
with one (1) shelf, powder coated finish, for typing paper (paper size: 8.5" x 13")
• color: beige
• light gray steel leg, with steel modesty front panel
• metal gauge 0.7mm before coating
• at least with a dimension of 60cm L x 60cm W x 74cm H
Long Table (for Court Room)
Specifications:
• 30mm postform with 2mm edgeband on sides
• Medium Density Fiber (MDF) Board table top, high pressure table top,
scratchproof, with second layer shelf, 2-3 seater
• color: beigie
• folding steel leg in powder coated finis with adjustable rubber footings
• metal gauge 0.7mm before coating
• at least with a dimension of 180cm W x 60cm D x 74cm H

Senior Executive Chair (for Judge)

Specifications:
• High back executive chair with armrest
• with contoure back rest design
• high density molded foam
• 350mm nylon certified bifma base and twin caster
• any standard balck leatherette upholstery
• with tilting mechanism
bifma gaslift, gaspost diameter 45mm X 275mm - 385mm;
• at least with a dimension of 62cm W X 50cm D X 75 (back rest)cm H

Junior Executive Chair (for CoC/BCoC)

Specifications:
• Medium back executive chair with armrest;
• With contoured back rest design;
• High density molded foam;
• 330mm nylon certified bifma base and twin casters;
• Any standard black leatherette upholstery;
• With tilting mechanism;
• Bifma gaslift, gaspost diameter 45mm x 275mm - 385mm
• Atleast with a dimension of 62cm W X 50cm D X 53 (back rest) cm H.

Clerical Chair Without Armrest

Specifications:
• Medium backrest without armrest;
• High density molded foam;
• 330mm nylon certified bifma base and twin casters;
• Any standard black leatherette upholstery;
• With tilting mechanism;
• Bifma gaslif, gapost diameter 45mmx 275mm-385mm;
• Atleast with a dimension of 50cm W X 45cm D X 45 (back rest) cm H.

Clerical Chair With Armrest

Specifications:
• Medium backrest with armrest; armrest: C Shape;
• High density molded foam;
• 330mm nylin certified bifma base and twin casters;
• Any standard blackleatherette upholster;
• With tilting mechanism;
• Bifma gaslift, gaspost diameter 45mm 275mm - 385mm

Visitor's Chair
Specifications:
 • Medium backrest without armrest;
• 4-legged guest chair in black frame
• Any standard leatherette upholstery (with foam: backrest and seat):
• Frame thickness 1.2mm;
• At least with a dimension of 53cm W X 40cm D X 40cm H.

Gang Chair
Specifications:
• 3-seater heavy duty power coated frame 5mm polypropelene materials
• on seat and back rest;
• With perforated backrest design;
• Black beam;
• Blue seat shell;
• Frame thickness 1.2mm; in royal blue 5mm thick PVC seat.

Sofa
Specifications:
• 3-seater sofa in black leatherette, firm cushion/foam;
• Without armrest on both sides;
• Wooden footings;
• Outer dimension with a least 164cm L x 80cm W x 80cm H.
 PRICE QUOTATION FORM

Date:

Clerk of Court

(Court, Branch, Station)

After having carefully read and accepted the terms and conditions in the Request for Quotation,
we are submitting our proposal as follows:

To be filled up by the branch/OCC To be filled up by supplier

Description of Items and Specifications Quantity Unit Price Total Bid Amount

₱ ₱

Delivery Charge (if applicable)

The above quoted prices are inclusive of applicable taxes.

Very truly yours,

Signature over Printed Name

Position

Company Name

Company Address

Contact No.
Business/Mayor's Permit No.:
DTI or SEC Registration Certificate No.:
PhilGEPS Registration No. (If any)
 REPORT OF WASTE MATERIALS

Court, Branch, Station: Place of Storage: Date:

Item Quantity Unit Particulars Remarks

CERTIFICATE OF INSPECTOR

I hereby certify that this property was disposed of as follows:

Item Destroyed
Item Sold at private sale
Item Sold at public auction
Item Transferred w/o cost to _______________________
Item Continued in service

Head of Maintenance: Witness to Disposition

Signature over Printed Name Signature over Printed Name

Noted by Executive Judge/ Presiding Judge/ Clerk of Court:

Signature over Printed Name Date

 REQUEST FOR QUOTATION

The _________________________________________________, is requesting for formal pri

(Court, Branch, Station)
quotation for the supply and delivery of _________________________________________, in accordan
(state item/s: various office supplies or furniture or equipment)
with Republic Act 9184, otherwise known as the Government Procurement Reform Act.

Delivery Period : Within _______ clendar days upon receipt of the Purchase Order

Prospective bidders shall accomplish, provide correct and accurate information and submit
the duly signed Price Quotation form (attached herewith) in as sealed envelope not later than
_________________________________ Quotations submitted after the said deadline shall not be
(Time and Date detrmined buy the branch/OCC)
accepted.

Quotations must be valid for a period of thity (30) calendar days from the date of submission.

Award shall be made to the lowest quotation which complies with the minimum technical
spcifications and other terms and conditions stated herein. Any interlineations, erasures or overwriting
shall be void unless signed or initialled by the bidder or its duly authorized representative.

The ____________________________ shall have the right to inspect and/ or test the goods to
(Court, Branch, Station)
verify their conformity to the technical specifications. Liquidated damages equivalent to one- tenth of
one percent (0.0001%) of the value of the goods not delivered within the prescirbed delivery period
shall be imposed per day of delay. The _________________________________________ shall cancel the
(Court, Branch, Staion)
Purchase Order once the cumulative amount of liquidated damages reaches ten percent (10%) of
the amount, without prejudice to other courses of action and remedies open to it. The ___________
_______________________________ reserves the right to accept or reject any or all quotations and to
(Court, Branch, Station)
impose additional terms and conditions as it may deem proper.

Date
Very truly yours,

Signature over Printed Name

Clerk of Court