Free VA Form FL-10-90 - Request to Firm to Submit Estimate of Cost of Purchase or Repair of Prosthetic D - Federal

DEPARTMENT OF VETERANS AFFAIRS

In Reply Refer To:

Your firm is being considered as a possible source for the following:

This letter is submitted to secure an estimate on the above-listed item(s). It in no way constitutes a purchase order; nor is it to be considered as authority for delivery or work to be started. If the veteran selects an item, you are requested to take any measurements that may be necessary. If an artificial limb or a new socket for a limb has been prescribed, please complete Part I, Stump Sock Measurements, on the back of this letter. If the item described above is covered under VA contract, enter your contract number and other pertinent information in the spaces provided in Part II. If the items selected are not covered by the contract, complete Part III, Informal Quotation. If a contract with you is currently in effect for the same class of appliance, the guarantee and other provisions as outlined therein will apply. If you do not have a current contract for the same class of appliance, please state in the space under "Articles or Services" the guarantee provisions applicable to this quotation. Upon completion of the estimate, return the original and one copy of this letter to the Department of Veterans Affairs facility indicated above. Consideration of the purchase of the above item(s) will be made, and, if approved, a purchase order to cover the appliance or repair will be prepared and forwarded to you. You may retain one copy of this letter for your files.

Sincerely,

FL 10-90 FEB 2005 (R)

(OVER)

OMB No. 2900-0188 Estimated Burden: 5 minutes Expiration Date: 10/30/2007

REQUEST TO SUBMIT ESTIMATE
This information is collected in accordance with section 3507 of the Paperwork Reduction Act of 1995. Accordingly, we may not conduct or sponsor, and you are notrequired to respond to, a collection of information unless it displays a valid OMB number. We anticipate that the time expended by all providers who must complete this formwill average 5 minutes. This includes the time it will take to read instructions, gather the necessary facts and fill out the form. The purpose of this form is to solicit a pricequote. Submission of this data is voluntary and failure to respond will have no adverse effect on any benefits to which the provider might otherwise be entitled. PART I - STUM P SOCK M EASUREMENTS PART II - CONTRACT ITEMS
M EA SUREM ENT INSTRUCTIONS - If stump sock is available, take measurements with sock lying flat. If no sock is available, measure stump circumference at top of prosthesis and 2 inches from stump end. For length, allow 3 inches for turn-down. For Syme' s,Chopart's or hip disarticulation amputations, send pattern or drawing.

NAME AND ADDRESS OF VENDOR VA CONTRACT NO. GROUP ITEM NUMBER CONTRACT PRICE

LEG M EASUREM ENTS SOCK SIZE NO. TOP (Inches) TOE (Inches) LENGTH (Inches) MATERIAL & PLY

RIGHT
SOCK STUMP

LEFT
SOCK STUMP

ADDITIONAL INFORMATION

RIGHT ARM M EA SUREM ENTS SOCK STUMP SOCK SIZE NO. TOP (Inches) TOE (Inches) LENGTH (Inches) MATERIAL & PLY
ADDITIONAL INFORMATION

LEFT
SOCK STUMP

SIGNATURE AND TITLE OF COMPANY OFFICIAL

DATE

PART III - INFORM AL QUOTATION FOR NONCONTRACT ITEM S
NAME AND ADDRESS OF VA FIELD FACILITY DELIVERY TO BE MADE F.O.B.

TO ITEM NO. ARTICLE OR SERVICES QUANTITY UNIT UNIT PRICE AMOUNT

BIDDER REPRESENTS THA T THE A GGREGA TE NUM BER OF EM PLOYEES OF THE BIDDER AND ITS AFFILIATES IS (Check Appropriate Box) 500 OR MORE LESS THAN 500

NAME OF VENDOR

DELIVERY TO BE MADE WITHIN (Specify number of days after receipt of purchase order):

BY (Signature)

TRADE DISCOUNT: CASH DISCOUNT

%

TITLE OF PERSON AUTHORIZED TO SIGN THIS QUOTATION

PAYMENT WITHIN 10 DAYS PAYMENT WITHIN 20 DAYS PAYMENT WITHIN 30 DAYS ADDRESS OF VENDOR (Number and street) CITY, STATE AND ZIP CODE

%
FL 10-90 FEB 2005 (R)

%

%

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