4-00250 Experience Equipmt and Finan Stmt.pdf

SECTION 00250

EXPERIENCE, EQUIPMENT AND FINANCIAL STATEMENT DIVISION 0

West Branch Regional Authority 00250-1 January 2026 Route 54 Sanitary Sewer Extension Project Experience, Equipment & Financial Statement Contract No. WB-1

Notice: Refer to Article 3, Qualifications of Bidders in Section 00200: Instructions to Bidders.

Bidders must complete ALL sections in full and sign, notarize and include it with their bid packet.

A. GENERAL INFORMATION

Project for which Bidder is qualifying

Date this Form submitted Date of receipt of bids

Submitted by Individual (Designate proper description - circle one)

Co-partnership Corporation Joint Venture

Business Address:

Telephone:

Email Address:

If a corporation, answer this: If a co-partnership, answer this:

Capital paid in cash:$ Date of organization When incorporated State whether partnership is general or limited In what State

Name, Address and Age of Corporate Officers or Partners:

President's name:

Vice-President's name:

Secretary's name:

Treasurer's name:

Number of permanent office and support employees:

Number of permanent field employees:

Contractor's Bonding Company (name and address):

Contractor's Insurance Company (name and address):

B. EXPERIENCE AND EQUIPMENT

1. How many years has your organization been in business as a general contractor under your present business name?

West Branch Regional Authority 00250-2 January 2026

2. How many years experience in this type of construction work has your organization had:

(a) As a general contractor (b) As a sub-contractor

(c) Pennsylvania Contractor License No.

3. What are the largest projects your organization has completed?

Contract Amount Class of Work When Completed Owner

1.

2.

3.

4.

5.

Name, address and phone number of Reference for items listed above:

1.

2.

3.

4.

5.

Any other reference

4. Have you ever failed to complete any work awarded to you?

If so, where and why?

5. Have you ever filed delay and/or monetary claims on a construction project(s)?

If so, what projects and why?

6. Have you or your company been in litigation from a construction project?

If so, what and why?

7. Have claims been set against you and/or your surety bonds on construction projects?

If so, what and why?

West Branch Regional Authority 00250-3 January 2026

8. Has the Contractor, or any of its parents or subsidiaries, ever had a bankruptcy petition filed in its name, voluntarily or involuntarily?

If yes, specify date, circumstances, resolution and other details on a separate page.

9. Are there any unresolved claims or disputes on any work awarded to the Contractor during the past five years?

If yes, give Owner's name and details on a separate page.

10. Does the Contractor maintain a permanent safety program?

If yes, attach a copy of the program.

11. Have you or any officer or partner of your organization ever been an officer or partner of another contracting organization?

If so, state name of individual, position and the name of the other organization.

12. If any part of the work is sublet, will you require a bond from sub-contractor?

13. Give a list of uncompleted contracts at present held by you.

Contract Amount

14. What equipment do you own that is available for the proposed work? Provide list of major equipment

(Manufacturer, Make, Model, Year, Hours of Operation).

15. Is the equipment rented or leased?

16. Who will perform maintenance on equipment?

17. Where will back-up equipment be obtained?

West Branch Regional Authority 00250-4 January 2026

18. State approximately the largest amount of work you have done in any one year

Remarks

C. FINANCIAL STATEMENT AS OF (Date):

Submit a certified financial statement for the Bidder's most recent accounting period. Submit a letter from Bidder's surety company specifying Bidder's total bonding capacity and current unused bonding capacity. Submit additional references and information sufficiently comprehensive to permit an appraisal of Bidder's current financial condition.

Contractor's Bank or Financial Institution (Name, Address, Contact number and person):

ASSETS

(Dollars)

1. Cash

2. Notes receivable:

(a) Due within 90 days

(b) Due after 90 days

(c) Past Due

3. Accounts receivable from completed contracts, exclusive of claims not approved for payment

4. Sums earned and not paid, on uncompleted contracts as shown by Engineer's or

Architect's estimate

(a) Amount receivable after deducting retainage

(b) Retainage to date, due upon completion of contracts

5. Accounts receivable from sources other than construction contracts

West Branch Regional Authority 00250-5 January 2026

6. Deposits for bids or other guarantees:

(a) Recoverable within 90 days

(b) Recoverable after 90 days

7. Real Estate owned and registered in the name of bidder - assessed value:

Description and Location of Property

8. Plant and equipment - actual value

9. Other assets

Total assets

LIABILITIES

1. Notes payable:

(a) Within 90 days

(b) After 90 days

2. Accounts payable

3. Real estate encumbrances

4. Other liabilities

5. Reserves

6. Capital stock paid up

7. Surplus (net worth)

Total Liabilities

CONTINGENT LIABILITIES

Liability on notes, accounts, or guarantee of others, and any judgments of record:

West Branch Regional Authority 00250-6 January 2026

CONTINGENT ASSETS

Bank credits, etc.

D. AFFIDAVIT

The undersigned guarantees the truth and accuracy of all statements and of all answers to interrogatories made and hereby authorizes any depository, vendor or other agency herein named to supply the holder with any information necessary to verify this statement.

NOTE: A co-partnership must give firm name and signature of all partners. A corporation must give full corporate name, signature of official (either president, vice-president, secretary or treasurer) and affix corporation seal.

AFFIDAVIT FOR INDIVIDUAL

STATE OF

COUNTY OF

being duly sworn, deposes and says that the foregoing financial statement, taken from the books, is a true and accurate statement of the financial condition as of the date thereof and that the answers to the foregoing interrogatories are true.

Sworn and subscribed to before me this day of 20

(Applicant must also sign here)

My commission expires:

Notary Public

AFFIDAVIT FOR CO-PARTNERSHIP

COUNTY OF

West Branch Regional Authority 00250-7 January 2026 being duly sworn, deposes and says that the foregoing financial statement, taken from the books, is a true and accurate statement of the financial condition as of the date thereof and that the answers to the foregoing interrogatories are true.

(Member of firm must also sign here)

AFFIDAVIT FOR LIMITED LIABILITY COMPANY OR CORPORATION

COUNTY OF

being duly sworn, deposes and says that he/she is of the :

the corporation described in and which executed the foregoing statement; that he/she is familiar with the books of the said corporation showing its financial condition; that the foregoing financial statement is taken from the books of the said corporation, and is a true and accurate statement of the financial condition of the corporation as of the date thereof; and that the answers to the foregoing interrogatories are true.

(Member of firm must also sign here)