DEPARTMENT OF ENERGY	BUYER/CARDHOLDER:  	
BERKELEY SITE OFFICE	MAILSTOP:  	
		DATE:  	

Request for Determination - Supplies of Foreign Origin

Pursuant to the provisions of Clause I.33, Buy American Act - Supplies, of Contract DE-AC02-05CH11231, your determination is requested in connection with the purchase of supplies listed below which originate in ____________________(country).  The requisition initiating the purchase of these supplies is properly authorized. Foreign supplies will be purchased from ________________________________(vendor) in the amount of $__________________ under Subcontract/Pcard Order Number  _______________.  The following information is considered pertinent:

Description of supplies/services if over $2,500:

Intended use:

The work requires:

We have concluded on the following basis that there are no domestic supplies satisfactory for the intended use:

It is determined that the above purchase is an exception to the Buy American Act – Supplies.

______________________________________	_________________
Requester		Date

______________________________________	_________________
Procurement Specialist/Pcardholder					Date

______________________________________	_________________
Procurement Supervisor (Sign & Print Name)		Date

______________________________________	_________________
Procurement Manager or designee 		Date
(If over $100,000, Sign & Print Name)		

______________________________________	_________________
DOE (If over $100,000)							Date