36E77618R0086-007.docx

ATTACHMENT 4 - PAST PERFORMANCE QUESTIONNAIRE

1. Contractor Information

Firm Name:

Address:

Phone Number:

Point of Contact:

Contact Phone Number:

DUNs Number:

2. Work Performed as: |_| Prime Contractor |_| Sub Contractor |_| Joint Venture |_| Other

Percent of project work performed:

If subcontractor, who was the prime (Name/Phone #):

3. Contract Information Contract Number:

Delivery/Task Order Number (if applicable):

Contract Type: |_| Firm Fixed Price |_| Cost Reimbursement |_| Other (Please specify):

Contract Title:

Contract Location:

Project Description:

Complexity of Work |_| High |_| Med |_| Routine Award Date (mm/dd/yy):

Contract Completion Date (mm/dd/yy):

Actual Completion Date (mm/dd/yy):

Explain Differences:

Original Contract Price (Award Amount):

Final Contract Price (to include all modifications, if applicable):

Explain Differences:

Rating: Please evaluate the past performance using only the following ratings without variation. DO NOT RATE ON A “+” OR “-“ SCALE. If a “+” or “-“ is used, the rating without the "+" or "-" will be applied. In addition to the ratings, please provide a short narrative in the appropriate block or in the remarks section of this form.

Please rate and provide any supporting information/comments for the following:

3. The responsiveness to the client’s needs and expectations.

O A S M U

7. Any Value added to the project as the result of cost savings, favorable financing, positive asset management, etc.

Yes No

10. Other relevant aspects in the management of a project development for the client.

Signature of Evaluator

Date