GSA_527_(2).pdf

GENERAL SERVICES ADMINISTRATION GSA 527 (REV. 10/2015)

Paperwork Reduction Act Statement - This information collection meets the requirements of 44 USC § 3507, as amended by section 2 of the Paperwork Reduction Act of 1995. You do not need to answer these questions unless we display a valid Office of Management and Budget (OMB) control number. The OMB control number for this collection is 3090-0007. We estimate that it will take 2.5 hours to read the instructions, gather the facts, and answer the questions. Send only comments relating to our time estimate, including suggestions for reducing this burden, or any other aspects of this collection of information to: General Services Administration, Regulatory Secretariat Division (M1V1CB), 1800 F Street, NW, Washington, DC 20405.

SECTION I - GENERAL INFORMATION

1A. NAME 2. TYPE OF ORGANIZATION (Check one)

A. SOLE PROPRIETORSHIP F. LIMITED LIABILITY COMPANY

1B. STREET ADDRESS B. GENERAL PARTNERSHIP G. JOINT VENTURE

C. LIMITED PARTNERSHIP H. TRUST

1C. CITY 1D. STATE 1E. ZIP CODE D. CORPORATION I. OTHER (Specify below)

E. SUBCHAPTER S CORPORATION

3. TAXPAYER ID NUMBER 4. DATE ORGANIZATION ESTABLISHED 5. STATE OF INCORPORATION

6. TRADE STYLE NAME (Provide a copy of filing) 7. KIND OF PRODUCT OR SERVICE PROVIDED

8. FORMER BUSINESS NAME 10. INVENTORY VALUATION METHOD

A. LIFO

C. AVERAGE COST

9. KIND OF BUSINESS

A. MANUFACTURER D. RETAILER

B. FIFO

D. OTHER (Specify)

B. CONTRACTOR E. OTHER (Specify)

C. WHOLESALER

11. OWNERSHIP INFORMATION-PARTNERS-PRINCIPAL STOCKHOLDERS-OTHERS

NAME

TITLE

(If partner, state G(General) or L(Limited) in column) PERCENT

BUSINESS OWNED

ACTUAL TITLE G OR L

12. PARENT COMPANY (If applicable)

13. IF "YES" TO ANY QUESTION BELOW, PROVIDE DETAILED

INFORMATION IN SECTION VIII, REMARKS YES NO

A. HAVE YOU, OR ANY OF YOUR AFFILIATES EVER FILED FOR BANKRUPTCY? A. NAME

B. DO YOU HAVE ANY JUDGMENTS, LIENS, OR PENDING SUITS?

B. CITY C. STATE C. DO YOU HAVE ANY CONTINGENT LIABILITIES?

D. HAVE YOU OR ANY OF YOUR AFFILIATES DISCONTINUED BUSINESS OPERATIONS WITH

OUTSTANDING DEBTS?

SECTION II - GOVERNMENT FINANCIAL AID AND INDEBTEDNESS

14A. ARE YOU DELINQUENT ON ANY FEDERAL DEBT (OMB CIRCULAR A-129)

(If "Yes", provide detailed information, Section VIII, Remarks)

YES NO

14B. DO YOU OWE THE

GOVERNMENT

FOR ANY

CONTRACT OR

OTHER CLAIMS?

YES NO

IF "YES", COMPLETE THE ITEMS BELOW

AGENCY CLAIM AMOUNT PAYMENT MATURITY BALANCE

15A. AGENCY INVOLVED WITH DELINQUENCY 15B. AMOUNT OF DELINQUENCY ($)

16. ARE YOU

CURRENTLY

RECEIVING

GOVERNMENT

FINANCING?

YES

NO (Go to Section III )

17. COMPLETE ITEMS BELOW IF APPLICABLE

TYPE OF FINANCING AUTHORIZED ($) IN USE ($) GOVERNMENT AGENCY INVOLVED

A. INDUSTRIAL REVENUE BONDS

B. GUARANTEED LOANS

C. ADVANCED PAYMENTS

D. PROGRESS PAYMENTS

E. OTHER (Specify)

CONTRACTOR'S QUALIFICATIONS AND FINANCIAL INFORMATION OMB Control Number: 3090-0007 Expiration Date: 9/30/2021

GSA 527 (REV. 10/2015) PAGE 2

SECTION III - FINANCIAL STATEMENTS

Prepared Financial Statements with notes may be provided in lieu of completing Section III

When financial statements are prepared or certified by independent accountants and transcribed to this form, please furnish the name and address of accountant of accounting firm.

18. ARE YOU THE INCUMBENT CONTRACTOR FOR THIS SOLICITATION?

YES NO

19A. NAME 20. IF TRANSCRIBED STATEMENTS DIFFER FROM INDEPENDENT ACCOUNTANT'S,

PLEASE DESCRIBE ADJUSTMENT IN SECTION VII, REMARKS. ALL OF THE

LISTED FIGURES ARE: 19B. STREET ADDRESS

ACTUAL U.S. DOLLARS

19C. CITY 19D. STATE 19E. ZIP CODE IN THOUSANDS FOREIGN CURRENCY (Specify)

IN MILLIONS

21. BALANCE SHEET AS OF (Month, Day, Year)

22. FISCAL YEAR ENDS (Month, Day, Year) 23. PREPARED STATEMENTS

ARE ATTACHED

24. ASSETS 25. LIABILITIES AND NET WORTH

A. Current Assets A. Current Liabilities

Cash Accounts payable Short Term cash investments Notes payable (current) Accounts receivable, less allowance for doubtful accounts of $

Current portion of long term debt Accrued expenses

Inventories Accrued taxes on income/excess profits Other current assets (Itemize below) Other current liabilities (Itemize below)

Total Current Assets Total Current Liabilities B. Property, Plant and Equipment B. Other Liabilities

Land Mortgages Buildings and equipment Bonds Leasehold improvements Deferred income taxes Less accumulated depreciation and amortization

Other long term debt Total Other Liabilities Total Property, Plant and Equipment

C. Other Assets Total Liabilities Investments in and advance to affiliated company

C. Minority Interest in Subsidiary

Goodwill, less amortization D. Net Worth Due from officer, employee Preferred stock Other (Itemize below) Common stock

Additional paid-in capital Retained earnings/owner's equity Less, Treasury stock

Total Other Assets Total Net Worth

D. TOTAL ASSETS E. TOTAL LIABILITIES AND NET WORTH

SECTION IV - INCOME STATEMENT

28. INCOME

A. Net Sales Minority Interest in Earnings of Subsidiaries

Cost and Expenses

Cost of Goods Sold Total Costs and Expenses Depreciation and Amortization Selling, General, and Admin. Expenses Earnings Before Taxes Interest Expense Taxes on Income Other Expenses (Itemize below) Income Before Extraordinary Items

Extraordinary Gains (Losses) Net of Taxes

NET INCOME (LOSS)

26. FROM (Month, Day, Year) 27. TO (Month, Day, Year)

GSA 527 (REV. 10/2015) PAGE 3

SECTION V - BANKING AND FINANCE COMPANY INFORMATION

(Please attach a separate sheet using this format for any additional banks.)

ITEM BANK 1 BANK 2

29. Name of Bank

30. Contact Person

31. Phone Number

AREA CODE NUMBER EXTENSION AREA CODE NUMBER EXTENSION

32. Fax Number

AREA CODE NUMBER AREA CODE NUMBER

33. Address

STREET ADDRESS STREET ADDRESS

CITY STATE ZIP CODE CITY STATE ZIP CODE

34. Amount Owing ($)

35. Term Loans Yes No Yes No

36. Line of Credit Yes No Yes No

37. Maximum Amount Authorized ($)

38. Amount Outstanding ($)

39. Loans Secured by Company's Assets - Real and Personal Property

A.

SECURED PARTY NAME CONTACT NAME

STREET ADDRESS CITY STATE ZIP CODE

SECURING ASSETS MATURITY DATE MONTHLY PAYMENT ($)

B.

C.

D.

STREET ADDRESS CITY STATE ZIP CODE

SECURING ASSETS MATURITY DATE MONTHLY PAYMENT ($)

40. ARE ANY OF THE ASSETS SHOWN ON THE BALANCE SHEET

PLEDGED OR MORTGAGED, EXCEPT AS STATED ABOVE?

NO YES (Explain in Section VII, Remarks)

41A. IF CONTRACTOR IS A PARTNERSHIP OR SOLE PROPIERTORSHIP,

ARE THE INDIVIDUAL LIABILITIES OF THE PROPIETOR(S) FOR

FEDERAL AND STATE INCOME AND/OR EXCESS PROFIT TAXES

INCLUDED ON THE BALANCE SHEET?

YES NO

41B. TOTAL

LIABILITY ($)

42. ARE YOU NOW IN OR PENDING DEFAULT ON ANY OBLIGATIONS, I.E., BANKS, FINANCIAL INSTITUTIONS, SUPPLIERS, OTHER?

NO YES (Provide detailed information in Section VII, Remarks)

GSA 527 (REV. 10/2015) PAGE 4

SECTION VI - PRINCIPAL MERCHANDISE OR RAW MATERIAL SUPPLIER INFORMATION

(Please attach separate sheet(s) using this format for additional suppliers.)

43. PAST DUE ACCOUNTS PAYABLE ($)

ITEM 44. SUPPLIER 1 45. SUPPLIER 2

A. Name of Supplier B. Contact Person C. Telephone

AREA CODE NUMBER EXTENSION AREA CODE NUMBER EXTENSION

D. Fax

E. Address

CITY STATE ZIP CODE CITY STATE ZIP CODE

F. Amount Now Owing ($)

G. High Credit ($)

ITEM 46. SUPPLIER 3 47. SUPPLIER 4

A. Name of Supplier B. Contact Person C. Telephone

AREA CODE NUMBER EXTENSION AREA CODE NUMBER EXTENSION

CITY STATE ZIP CODE CITY STATE ZIP CODE

F. Amount Now Owing ($)

G. High Credit ($) SECTION VII - CONSTRUCTION/SERVICE CONTRACTS INFORMATION (Public Buildings Service Contracts Only)

CONTRACTS IN FORCE

ITEM 48. CONTRACT 1 49. CONTRACT 2

A. Location B. Owner's Name

C. Address

CITY STATE ZIP CODE CITY STATE ZIP CODE

D. Type of Work E. Contract Amount ($) F. Percent Completed G. Estimated Completion Date

ITEM 50. CONTRACT 3 51. CONTRACT 4

CITY STATE ZIP CODE CITY STATE ZIP CODE

D. Type of Work E. Contract Amount ($) F. Percent Completed

GSA 527 (REV. 10/2015) PAGE 5

LARGEST JOBS YOU HAVE COMPLETED IN THE LAST FIVE YEARS

ITEM 56. JOB 1 57. JOB 2

B. Contact's Name

CITY STATE ZIP CODE CITY STATE ZIP CODE

D. Telephone

AREA CODE NUMBER EXTENSION AREA CODE NUMBER EXTENSION

E. Type of Work F. Contract Amount ($) G. Amount Sublet ($)

ITEM 58. JOB 3 59. JOB 4

CITY STATE ZIP CODE CITY STATE ZIP CODE

D. Telephone

AREA CODE NUMBER EXTENSION AREA CODE NUMBER EXTENSION

E. Type of Work F. Contract Amount ($) G. Amount Sublet ($)

ITEM 60. JOB 5 61. JOB 6

CITY STATE ZIP CODE CITY STATE ZIP CODE

D. Telephone

AREA CODE NUMBER EXTENSION AREA CODE NUMBER EXTENSION

E. Type of Work F. Contract Amount ($) G. Amount Sublet ($)

ITEM 52. CONTRACT 5 53. CONTRACT 6

CITY STATE ZIP CODE CITY STATE ZIP CODE

D. Type of Work E. Contract Amount ($) F. Percent Completed

ITEM 54. CONTRACT 7 55. CONTRACT 8

CITY STATE ZIP CODE CITY STATE ZIP CODE

D. Type of Work E. Contract Amount ($) F. Percent Completed

GSA 527 (REV. 10/2015) PAGE 6

LIST COMPANIES FROM WHOM YOU OBTAIN SURETY BONDS

ITEM 62. SURETY COMPANY 1 63. SURETY COMPANY 2

A. Company Name B. Contact's Name C. Telephone

AREA CODE NUMBER EXTENSION AREA CODE NUMBER EXTENSION

CITY STATE ZIP CODE CITY STATE ZIP CODE

64. PRESENT AMOUNT OF BONDING

COVERAGE ($)

65. HAS YOUR APPLICATION FOR SURETY

BOND EVER BEEN DECLINED? (If Yes, please provide detailed information in Remarks)

YES NO

66. DURING THE PAST 2 YEARS, HAVE YOU BEEN CHARGED WITH A

FAILURE TO MEET THE CLAIMS OF YOUR SUBCONTRACTORS OR

SUPPLIERS? (If Yes, please provide detailed information in Remarks)

YES NO

SECTION VIII - REMARKS

REMARKS (Cite those sections of the form relating to your remarks. If additional space is required, attach additional sheet(s).)

CERTIFICATION

For the purpose of establishing financial responsibility with, or procuring credit from the General Services Administration, we furnish the above as a true and correct statement of our financial condition and further certify that all other statements are true and correct. There has been no material change in the applicant's financial condition since the date of the above statement. We agree to notify you immediately in writing of any materially unfavorable change in our financial condition. In the absence of such notice or of a new and full financial statement, this is to be considered as a continuing statement.

NAME OF BUSINESS BY (Signature of Authorized Official)

NAME OF AUTHORIZED OFFICIAL (Type or print) DATE

TITLE OF AUTHORIZED OFFICIAL (Type or print)