Form IHS-975 Request for Ratification of Unauthorized Commitment (Uac)

Form IHS-975 is a U.S. Department of Health and Human Services - Indian Health Service form also known as the "Request For Ratification Of Unauthorized Commitment (uac)". The latest edition of the form was released in April 1, 2018 and is available for digital filing.

Download a PDF version of the Form IHS-975 down below or find it on U.S. Department of Health and Human Services - Indian Health Service Forms website.

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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Indian Health Service
REQUEST FOR RATIFICATION OF UNAUTHORIZED COMMITMENT (UAC)
Federal Acquisition Regulation (FAR) 1.602-3
HHS Acquisition Regulation (HHSAR) 301.602.-3
Purchase Request Number IHS
Amount ($)
Area Office/Service Unit/Program Office or HQ Office/Division
For (Item or Service)
Date of Commitment
To (Vendor/Contractor Name and Address)
The following section are to be completed by
Part I - Description of Commitment and Service Unit/Area or HQ Review
Section A, to be completed by individual who committed UAC
Section B, to be completed by Funds Certifying Official
Section C, to be completed by Immediate Supervisor
Section D, Service Unit CEO or Area/HQ Office Program Director - Review and Concurrence
Section E, Area Office / HQ Executive Officer - Review and Concurrence
Part II - Area or HQ Division of Acquisition's Review/Recommendation
Section A, to be completed by Contracting Officer
Section B, to be completed by Chief of the Contracting Office
Part III - Legal Review, Office of The General Counsel (OGC), Required for $150,000 and Above
Part IV - Approval, Head of the Contracting Activity (HCA)
PART I - SECTION A - COMMITMENT CIRCUMSTANCES
The individual who made the unauthorized commitment shall complete items 1 thru 5 of Part I, Section A, provide detailed facts,
required documentation, electronically sign, date, and forward to the immediate supervisor for completion of Part I - Section B.
1. Describe Circumstances that Led to the Unauthorized Commitment
IHS-975 (4/18)
PAGE 1 of 10
PSC Publishing Services (301) 443-6740
EF
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Indian Health Service
REQUEST FOR RATIFICATION OF UNAUTHORIZED COMMITMENT (UAC)
Federal Acquisition Regulation (FAR) 1.602-3
HHS Acquisition Regulation (HHSAR) 301.602.-3
Purchase Request Number IHS
Amount ($)
Area Office/Service Unit/Program Office or HQ Office/Division
For (Item or Service)
Date of Commitment
To (Vendor/Contractor Name and Address)
The following section are to be completed by
Part I - Description of Commitment and Service Unit/Area or HQ Review
Section A, to be completed by individual who committed UAC
Section B, to be completed by Funds Certifying Official
Section C, to be completed by Immediate Supervisor
Section D, Service Unit CEO or Area/HQ Office Program Director - Review and Concurrence
Section E, Area Office / HQ Executive Officer - Review and Concurrence
Part II - Area or HQ Division of Acquisition's Review/Recommendation
Section A, to be completed by Contracting Officer
Section B, to be completed by Chief of the Contracting Office
Part III - Legal Review, Office of The General Counsel (OGC), Required for $150,000 and Above
Part IV - Approval, Head of the Contracting Activity (HCA)
PART I - SECTION A - COMMITMENT CIRCUMSTANCES
The individual who made the unauthorized commitment shall complete items 1 thru 5 of Part I, Section A, provide detailed facts,
required documentation, electronically sign, date, and forward to the immediate supervisor for completion of Part I - Section B.
1. Describe Circumstances that Led to the Unauthorized Commitment
IHS-975 (4/18)
PAGE 1 of 10
PSC Publishing Services (301) 443-6740
EF
PART I - SECTION A - COMMITMENT CIRCUMSTANCES (Continued)
2. Explain Why Appropriate Acquisition Mechanism Was Not Followed and Why Vendor Was Selected
3. Statement That Funds Are and Were Available at Time of Unauthorized Commitment
4. Describe the Benefits Received by The Government (Give value of benefit and other pertinent facts) and if Service or Goods Have
Been Received
5. List Below and Attach All Relevant Documents (Include orders, invoices, fund availability, requisition and other evidence of the
transaction. Verify accuracy and completeness of documentation)
Signature
Date (mm/dd/yy)
Name, and Title of Individual Who Made the Unauthorized Commitment
IHS-975 (4/18)
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PART I - SECTION B - CONTRACTUAL RATIFICATION
The funds certifying official will complete items 6 thru 7 of Part I, Section B, electronically sign, date, and return the form to the individual
who committed UAC.
6. Availability of Funds
Are Unobligated Funds Presently Available for the Amount of the Unauthorized Commitment?
Yes
No
If yes, identify the CAN or approved requisition number
7. Funds Certification
I have Reviewed the Acquisition and Certify that Funds Were Available at the Time of the Occurrance, and Remain Available for
the Project.
No
Yes
Signature
Date (mm/dd/yy)
Funds Certifying Official Name, Title and Area or HQ Office/Service Unit/Program
IHS-975 (4/18)
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PART I - SECTION C - CONTRACTUAL RATIFICATION
The Immediate Supervisor Will Complete Items 8 thru 10 of Part I, Section C, Electronically Sign, Date, and Forward to Service Unit
CEO or Area/HQ Office Program Director.
8. Describe Attempts to Resolve Unauthorized Commitment Prior to Requesting Ratification (Such as, returning merchandise, individual
paying from personal funds, etc.)
9. Describe Corrective Action Taken or an Explanation of Why None Was Considered Necessary (Include a description of any
administrative action taken under applicable personnel authority)
10. Describe Action Taken to Prevent Recurrence of Unauthorized Commitments
Signature
Date (mm/dd/yy)
Immediate Supervisor Name, Title and Area or HQ Office/Service Unit/Program
IHS-975 (4/18)
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PART I - SECTION D - CONTRACTUAL RATIFICATION
The Service Unit CEO or Area/HQ Office Program Director Will Complete Section D of Part I. (Section B & C, in Some Instances, May
be the Same Person)
Approval of Corrective Action Taken
No
Yes
If no, explain non-concurrence
Approval of Action(s) to Preclude Recurrence of Unauthorized Commitments
Yes
No
If no, explain non-concurrence
I Have Reviewed Sections A and B of Part I, Verified That the Information is Accurate and Complete, That The Government Received a
Benefit and Associated Value from the Unauthorized Commitment, That Certified Funds Were Available at the Time of UAC and
I concur with the ratification of the unauthorized commitment
I do not concur with the ratification of the unauthorized commitment
If no, explain non-concurrence
Completed Purchase Description and Funding Document is Executed and Attached (Required if Ratification is Recommended).
Funding Document Must Specifically State That Funds Were Available at the Time the Unauthorized Commitment Was Made and
These Funds are Still Available.
No (action will not be ratified)
Yes
Signature
Date (mm/dd/yy)
Service Unit CEO/AREA or HQ Office Program Director Name, Title and Service Unit/Office
IHS-975 (4/18)
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Download Form IHS-975 Request for Ratification of Unauthorized Commitment (Uac)

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