Attachment 4 Contractors Financial Info.docx

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Replace Roof on East Wing of Osceola District Office
Solicitation number
12445121Q0004
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Attachment 4 Contractors Financial Info.docx DOCX document
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Attachment 2 Designation of Representative.pdf PDF

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ATTACHMENT 4

CONTRACTOR’S FINANCIAL INFORMATION

SECTION 1 – GENERAL INFORMATION

1A.NAME
2. TYPE OF ORGANIZATION (CHECK ONE)

A. Sole Proprietorship

F. LLC

1B. STREET ADDRESS

B. General Partnership

G. Joint Venture

C. Limited Partnership

H. Non-Profit/Education

1C. CITY
1D. STATE
1E. ZIP/POSTAL

D. Corporation

i. Other: Specify

E. Subchapter S.

3. TAXPAYER ID NUMBER :
4. PHONE NUMBER
5. FAX NUMBER
6. DUNS NUMBER:
7. FFIS VENDOR CODE: (FS VENDORS)
8. KIND OF PRODUCT OR SERVICE PROVIDED:
9. EMAIL ADDRESS

10. KIND OF BUSINESS- Specify one block (plus “J” if applicable)

A. LARGE BUSINESS

E. WOMAN OWNED SDB

I. INDIAN SDB

B. SMALL BUSINESS

F. VETERAN SMALL BUSINESS

J. HUB ZONE - Also

C. SMALL DISADVANTAGED BUSINESS

G. VETERAN SDB

K. Other: Please Specify

D. WOMAN OWNED SMALL BUSINESS

H. INDIAN SMALL BUSINESS

11. OWNERSHIP INFORMATION – PARTNERS – PRINCIPALS - OTHERS

NAME
TITLE

13.

14.

15.

16. Questions. If “Yes” to any below, provide detailed information in section vii, remarks.
Yes
No

A. Have you/your affiliates ever filed for bankruptcy?

B. Do you have any judgments, liens, pending suits?

C. Do you have any contingent liabilities?

D. Have you/your affiliates discontinued business operations with outstanding debts

SECTION II. GOVERNMENT FINANCIAL AID AND INDEBTEDNESS

If “Yes” provide detailed information in Section VII, remarks.

Yes
No

17. Are you delinquent on any Federal Debt (OMB Circular 129)

18. Do you owe the Government for any contract or other claims?

19. Are you currently receiving Government Financing? (Bonds, Loans, Advanced Payments, Progress Payments, Other)

19a. Are you now in or pending Default on ANY Obligations (i.e. Banks, Financial Institutions, Suppliers, Other)? IF yes please provide detailed information in Section VII remarks.

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