J2_ATTACHMENT.docx

MODEL CENTER WRITTEN TECHNICAL RFP

ATTACHMENT J-2 – STATEMENT OF FINANCIAL CAPABILITY

U.S. DEPARTMENT OF LABOR * Employment and Training Administration

RFP NO.

STATEMENT OF FINANCIAL CAPABILITY

(Insert the Name and Complete

Mailing Address of Offeror)

A. DATE LAST BALANCE

WAS PREPARED

B. FINANCIAL CONDITION

(As of Date) _______________ 19____

(1) Cash .........................................................$___________________

(2) Current Assets .........................................$___________________

(3) Current Liabilities .....................................$___________________

(4) Net Worth ................................................$___________________

PERIOD COVERED (Month, Day, Year)

From

To

C. DATE FISCAL YEAR ENDS

(Month, Day, Year)

D. FINANCIAL ARRANGEMENTS TO FACILITATE PERFORMANCE DURING INITIAL PHASE OF CONTRACT ("X" appropriate box(es))

(1) Own Resources

(2) Bank credit

If "YES" complete

a. Name of Bank(s):

b. Amount

(3) Other (If "YES", specify)

No

E. IF ADVANCE PAYMENT IS INDICATED UNDER D(3) ABOVE, COMPLETE THE FOLLOWING:-

(1) Estimated Amount of Advance Payment

$_______________________ for ___________ months.

(2) The following advances from the Government are presently being received: (Complete Columns "a" thru "e" below)

AGENCY'S NAME AND ADDRESS

PERIOD

OF

CONTRACT

CONTRACT NO.

AMOUNT

OF

ADVANCE

BANK

AGREEMENT WITH

ETA 8554 (Mar. 1981)

F. THE FOLLOWING IS A LIST OF CURRENT CONTRACTS WITH THIS OR ANY OTHER GOVERNMENT AGENCIES.

(If additional space is needed, attach additional sheet(s))

AGENCY'S NAME, ADDRESS, AND TELEPHONE NO.

CONTRACT NO.

AMOUNT

OF

CONTRACT

PERIOD OF CONTRACT

G. IF OVERHEAD/INDIRECT COSTS ARE INCLUDED IN YOUR COST PROPOSAL, THE FOLLOWING DATA WILL BE FURNISHED.

(1) Name and Address(es) of Cognizant Government Audit Agency

(2) Name and Address of Government Auditor

Telephone Area Code No. ( )

(3) Date Last Rate was Computed (Month, Day, Year) and Negotiated ─────────────────────────────────

(4) If no government audit agency computed and authorized the rate claimed, complete (a), (b), and (c) below.

(a) How it is computed?

(b) Who?

(c) Date (Mo., Day, Yr.)

ATTACH COMPUTATION DATA USED.

COMMENTS

CERTIFICATION:

I CERTIFY that to the best of my knowledge and belief the information contained herein is TRUE and CORRECT.

SIGNATURE

TYPED NAME AND TITLE

DATE (Mo., Day, Yr.)