20R0003-0001-RDF-ATTACHMENT-5.pdf

ATTACHMENT-5

RESPONSIBILITY DETERMINATION FORM

The following information is provided to assist the Contracting Officer in determining whether or not the proposed contractor meets the general standards of responsibility enumerated at FAR 9 .104-1 and DF ARS 209 .104-1.F AR 9 .104-1 General Standards. To be determined responsible, a prospective contractor must:

a) HA VE THE FINANCIAL RESOURCES TO PERFORM THE CONTRACT, OR THEABILITY TO OBTAIN THEM (SEE 9.104-3(b))

Financial Statements

Provide a copy of the latest financial statements (Balance Sheet and Income Statement. If the fmancial statements are older than one year, furnish a statement as to the current fmancial status of the company.

Banking References

Provide signed reference on letterhead from fmancial institution supporting each banking reference.

Bank Name ________ Address: ____________ _ Telephone#: _________ POC: ____________ _ Title: __________ Length of time with bank: _______ _ Credit Ratin..,_ ______ Number/type of accounts: _______ _ Amount in each account (#ofFigures): ____ Credit line: _______ _ Secured/Unsecured ______ Outstanding loans: ________ _

Bank Name ________ Address: ____________ _ Telephone#: _________ POC: ____________ _ Title: __________ Length of time with bank: _______ _ Credit Ratin..,_ ______ Number/type of accounts: _______ _ Amount in each account (#ofFigures): ____ Credit line: _______ _ Secured/Unsecured ______ Outstanding loans: ________ _

b) HA VE A SATISFACTORY RECORD OF INTEGRITY AND BUSINESS ETHICS

Trade References

1st company: ______ Telephone #: _____ _ Address: Name: Title:

Length of time with company: ________ Credit line: ______ Average monthly business:

High credit: Payment history: ________ Takes discounts: _____ _

2nd company: ______ Telephone #: _____ _ Address: _______ Name: _______ Title: _________ _ Length of time with company: Credit line: Average monthly business:

High credit: Payment history: ________ Takes discounts: _____ _

c) HAVE THE NECESSARY ORGANIZATION, EXPERIENCE, ACCOUNTING AND OPERATIONAL

CONTROLS, AND TECHNICAL SKILLS, OR THE ABILITY TO OBTAIN THEM (INCLUDING, AS

APPROPRIATE, SUCH ELEMENTS AS PRODUCTION CONTROL PROCEDURES, PROPERTY

CONTROL SYSTEMS, QUALITY ASSURANCE MEASURES, AND SAFETY PROGRAMS

APPLICABLE TO MATERIALS TO BE PRODUCED OR SERVICES TO BE PERFORMED BY THE

PROSPECTIVE CONTRACTOR AND SUBCONTRACTORS) (SEE 9.104-3(b))

Workman's Compensation Experience Modification Rate (EMR):

2016 2017 2018

Note: An EMR greater than 1.0 must be explained and supported documentation provided. (IfEMR's are not available, provide documentation from insurance provider documenting whether or not any claims resulting from work related injuries have been filed against the firm in the last three years or any other documentation that to establish safety record.)