12445124R0007 Attachment 008 Exhibit A CON FIN INFO SHEET FILLABLE.pdf
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- Solicitation number
- 12445124R0007
About this file
This document is the Contractor's Financial Information Sheet for a federal contract opportunity related to road construction and maintenance services for the National Forests and Grasslands of Texas.
The key details are: This is an Indefinite Delivery/Indefinite Quantity (IDIQ) Multiple Award Task Order Contract (MATOC) solicitation for up to 4 small business contracts with a minimum guarantee of $2,000 per contractor and individual contract ceiling of $3,000,000. The work includes road maintenance services such as grading, cleaning ditches, and roadside mowing, as well as road construction services like slide removal and culvert replacement. The contracts will have a base period of 12 months and one 24-month option period. The solicitation will be available on SAM.gov no earlier than July 29, 2024, and prospective offerors must be registered in SAM to be considered for award.
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Text version
Road Construction Services
Exhibit A: CONTRACTOR’S FINANCIAL INFORMATION SHEET
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. SAM UNIQUE ID NUMBER: 7. CELLPHONE NUMBER
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. EMERGING SMALL
BUSINESS
I. INDIAN SDB
B. SMALL BUSINESS F. VETERAN SMALL BUSINESS J. HUB ZONE - Also
C. SMALL DISADVANTAGED BUSINESS G. SERVICE DISABLED
VETERAN OWNED SMALL
BUSINESS
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, attach detailed information. 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”, attach detailed information.
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 attach detailed information.
Solicitation Number:
Forest/State:
Attachment 008 12445124R0007
| 2 TYPE OF ORGANIZATION CHECK ONE1ANAME: |
| A Sole Propr etorship: |
| 2 TYPE OF ORGANIZATION CHECK ONE1B STREET ADDRESS: |
| B General Partnersh p: |
| 2 TYPE OF ORGANIZATION CHECK ONE1B STREET ADDRESS_2: |
| C Lim ted Partnership: |
| 1C CITY: |
| 1D STATE: |
| 2 TYPE OF ORGANIZATION CHECK ONE1E ZIPPOSTAL: |
| 2 TYPE OF ORGANIZATION CHECK ONE1E ZIPPOSTAL_2: |
| 2 TYPE OF ORGANIZATION CHECK ONERow4: |
| I Other Spec fy: |
| 3 TAXPAYER ID NUMBER: |
| 4 PHONE NUMBER: |
| 5 FAX NUMBER: |
| 6 DUNS NUMBER: |
| 7 CELLPHONE NUMBER: |
| 8 KIND OF PRODUCT OR SERVICE PROVIDED: |
| 9 EMAIL ADDRESS: |
| 10 KIND OF BUSINESSSpec fy one block plus J f app cab eRow1: |
| A LARGE BUSINESS: |
| E EMERGING SMALL BUSINESS: |
| 10 KIND OF BUSINESSSpec fy one block plus J f app cab eRow2: |
| B SMALL BUSINESS: |
| F VETERAN SMALL BUSINESS: |
| 10 KIND OF BUSINESSSpec fy one block plus J f app cab eRow3: |
| C SMALL DISADVANTAGED BUSINESS: |
| 10 KIND OF BUSINESSSpec fy one block plus J f app cab eRow4: |
| D WOMAN OWNED SMALL BUSINESS: |
| 10 KIND OF BUSINESSSpec fy one block plus J f app cab eRow3_2: |
| K Other P ease Spec fy: |
| TITLE12: |
| TITLE13: |
| TITLE14: |
| TITLE15: |
| YesA Have youyour aff ates ever f ed for bankruptcy: |
| NoA Have youyour aff ates ever f ed for bankruptcy: |
| YesB Do you have any udgments ens pending suits: |
| NoB Do you have any udgments ens pending suits: |
| YesC Do you have any cont ngent abi t es: |
| NoC Do you have any cont ngent abi t es: |
| YesD Have youyour aff ates discont nued bus ness operat ons w th outstanding debts: |
| NoD Have youyour aff ates discont nued bus ness operat ons w th outstanding debts: |
| Yes17 Are you del nquent on any Federal Debt OMB C rcular 129: |
| No17 Are you del nquent on any Federal Debt OMB C rcular 129: |
| Yes18 Do you owe the Government for any contract or other c a ms: |
| No18 Do you owe the Government for any contract or other c a ms: |
| Yes19 Are you current y receiv ng Government F nanc ng Bonds Loans Advanced Payments Progress Payments Other: |
| No19 Are you current y receiv ng Government F nanc ng Bonds Loans Advanced Payments Progress Payments Other: |
| Yes19a Are you now n or pending Default on ANY Ob gat ons e Banks F nanc a Inst tut ons Suppl ers Other IF yes please attach deta ed nformat on: |
| No19a Are you now n or pending Default on ANY Ob gat ons e Banks F nanc a Inst tut ons Suppl ers Other IF yes please attach deta ed nformat on: |
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