Financial_Information_form.pdf

127K1119R0003 ATTACHMENT 1

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. DUNS 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.