7. Business Management Questionnaire Rev.pdf

FEDERAL BUREAU OF PRISONS

SERVICE CONTRACT BUSINESS MANAGEMENT QUESTIONNAIRE

Purpose:

The policy of the Federal Bureau of Prisons in acquiring services is to encourage firms lawfully engaged in the practice of performing Government required services to submit a statement of qualifications and performance data.

This questionnaire should only be submitted by a related services organization when requested to do so by the specific provisions of a solicitation, requested by the Contracting Officer, or public announcement.

This questionnaire may be used as a basis for selecting firms for discussions, or screening organizations preliminary to inviting submission of additional information.

Definitions:

(a) “Principals” are those individuals in a firm who possess legal responsibility for its management.

They may be officers, directors, owners, partners, and persons having primary management or supervisory responsibilities within a business entity (e.g., general manager, plant manager, head of a subsidiary, division or business segment, and similar positions).

(b) “Parent Company” is that firm, company, corporation, association, or conglomerate which is the major stockholder or highest tier owner of the firm completing the questionnaire; (i.e. Firm A is owned by Firm B which is, in turn, a subsidiary of Corporation C. The "parent company" is Corporation C).

(c) “Joint Venture” is a collaborative undertaking by two or more firms or individuals for which the participants are both jointly and individually responsible.

(d) “Consultant” as used in this questionnaire, is a highly specialized individual or firm having significant input and responsibility for certain aspects of a project and possessing unusual or unique capabilities for assuring success of the finished work.

(e) “Specialists and Individual Consultants” as used in this questionnaire, refer to individuals who have major project responsibility, or will provide unusual or unique capabilities for the services under consideration.

(f) “Discipline” as used in this questionnaire, refers to the primary capability of individuals in the responding firm. Possession of an academic degree, professional registration, certification, or extensive experience in a particular field of practice normally reflects an individual's primary discipline.

(g) “Prime” refers to that firm which may be coordinating the concerted and complementary inputs of several firms, individuals or related services produce a completed task. The prime would normally be regarded as having full responsibility and liability for quality of performance by itself, as well as by subcontractor professionals under its jurisdiction.

Instructions for Filing: ALL INFORMATION SUBMITTED IN RESPONSE TO THIS QUESTIONNAIRE SHALL BE CURRENT AND FACTUAL. (Provide information responding to Items 1 through 4 as an attachment):

PROJECT INFORMATION:

1. Give name and location of the project for which this questionnaire is being submitted.

2. Type accurate and complete name of submitting individual, firm (or joint venture), address, and zip code. Include date of preparation. (Attach additional pages, if necessary.)

a. Include the name, title, email, and telephone number of not more than two principals who will serve as the point of contact. Such individual(s) must be empowered to speak for the firm on policy and contractual matters and should be familiar with the programs and procedures of the agency to which this questionnaire is directed. (Attach additional pages, if necessary.)

b. Give the address of the specific office which will have responsibility for performing the announced work. (Attach additional pages, if necessary.)

3. Provide the number of personnel by discipline presently employed (on the date of this questionnaire) at office specified in 2b above. While some personnel may be qualified in several disciplines, each person should be counted only once in accord with their primary function.

Include clerical personnel as "administrative." (Attach additional pages, if necessary.)

4. Provide the names and addresses of all individuals, organizations, and primary subcontractors expected to be included as part of the venture and describe their particular areas of responsibility, (i.e., administration, financial, architectural, structural, mechanical, electrical, civil, environmental, etc.). (Attach additional pages, if necessary.)

a. Indicate whether these particular entities have worked together on other projects, if any, and include a brief description. (Attach additional pages, if necessary.)

GENERAL CONTRACTOR INFORMATION:

1. Organization Name and DUNS Number:

2. How many years has the organization been in business as a residential services contractor?

3. Under what other or former names has your organization operated?

4. If your organization is a corporation, provide the following:

(a) Date of incorporation:

(b) State of incorporation:

(c) Identify President (CEO), Vice President, Treasurer and Secretary (include Date of Birth, Place of Birth, Social Security Number, Race and Gender):

5. If your organization is a partnership, provide the following:

(a) Date of organization:

(b) Type of partnership (if applicable):

(c) Name(s) of general partner(s) (include Date of Birth, Place of Birth, Social Security Number, Race and Gender):

6. If your organization is individually owned, provide the following:

(a) Date of organization:

(b) Name of owner (include Date of Birth, Place of Birth, Social Security Number, Race and Gender):

(c) If the form of your organization is other than that listed above, describe it and the name of the principals (include Date of Birth, Place of Birth, Social Security Number, Race and Gender):

7. LICENSING. (Attach additional pages as necessary.)

(a) List jurisdiction and trade categories in which your organization is legally qualified to do business, and indicate registration or license numbers, if applicable.

(b) List jurisdictions in which your organization's or trade name is filed.

8. EXPERIENCE. (Attach additional pages as necessary.)

(a) List the categories of work that your organization performs.

(b) Claims and Suits. (If the answer to any of the questions below is yes, attach details.)

(i) Has your organization and/or its principals ever failed to complete any work awarded to it?

(ii) Are there any judgements, claims, arbitration proceedings or suits pending or outstanding against your organization or its officers or its principals?

(iii) Has your organization or its principals filed any lawsuits or requested arbitration with regard to contracts within the last five years?

(c) Has any personnel of your organization ever been an officer of another organization when it failed to complete a contract? (If yes, attach details.)

(d) Has your organization or any of the principals declared bankruptcy within the past seven years? (If yes, attach details.)

(e) List all past and present contracts with the Federal Government awarded to you, your organization, or any of the principals (Attach additional pages, if necessary).

9. FINANCIAL DATA. (Attach additional pages as necessary.)

(a) Trade References

(b) Bank Reference: Include a point of contact and their email and telephone number

10. PROOF OF FINANCING

(a) Attach a financial statement, preferably audited, including your organization's latest balance sheet, cash flow statement, and income statement providing at a minimum the following items:

(i) Current Assets (e.g., cash, joint venture accounts, accounts receivable, notes receivable, accrued income, deposits, materials inventory, and prepaid expenses);

(ii) Net fixed Assets; Other Assets;

(iii) Current liabilities (e.g., accounts payable, notes payable, accrued expenses, provision for income taxes, advances, accrued salaries and accrued payroll taxes);

(iv) Other liabilities (e.g., capital, capital stock, authorized and outstanding shares per values, earned surplus and retained earnings).

(b) Name and address of firm preparing attached financial statement, and date:

(c) Is the attached financial statement for the identical organization named on page one? If not, explain the relationship and financial responsibility of the organization whose financial statement is provided (e.g., parent-subsidiary).

11. SIGNATURE

18 U.S.C. 1001, False Statements Act provides:

Whoever, in any matter within the jurisdiction of any department of agency of the United States knowingly and willingly falsifies, conceals or covers up by any trick, scheme, or device a material fact, or makes any false, fictitious or fraudulent statements or representation, or makes or uses any false, fictitious or fraudulent statement or entry, shall be fined not more than $10,000 or imprisoned not more than five years, or both.

Dated this day of 20

Name of Organization

By:

Title:

M being duly sworn deposes and says that the information herein is true and sufficiently complete so as not to be misleading.

Subscribed and sworn before me this day of 20

Notary Public: My Commission Expires: