Attachment L-A Information Form.doc

Attachment L-A Past-Performance Reference Information Form

1. Complete name of Government agency, commercial firm, or other organization

2. Complete address

11. Project/Contract Title

12. Description of contract work (Describe nature and scope)

13. Current Status of Contract (choose one)

[ ] Work Continuing, On Schedule [ ] Work Continuing, Behind Schedule

[ ] Work Completed, No further Action Pending or Underway [ ] Work Completed, Routine Administrative Action Pending or Underway [ ] Work Completed, Litigation Pending or Underway [ ] Terminated for Convenience [ ] Terminated for Default [ ] Other (explain):

Attach additional sheet if necessary (one additional sheet maximum)

Instructions for Completing the Reference Information Worksheet

Item 1.

Insert the complete name and address of the customer, including parent organization, if any. Do not use acronyms.

Item 2.

Insert the customer’s complete address, including both post office box and street address, if applicable.

Item 3.

Insert any contract number or other contract reference used by the customer and contract type.

Item 4.

Insert the date on which the contract came into existence.

Item 5.

Insert the date on which you started to perform the work.

Item 6.

Insert the date on which the customer agreed that the work was satisfactorily completed (including substantial completion), aside from any pending or on-going administrative actions, claims negotiations, or litigation.

Item 7.

Insert the contract type and contract value (separately listing fee if cost-type).

Item 8.

Insert the final sum of all invoices, or the sum of all invoices to date, including agreed upon and disputed amounts, paid and awaiting payment.

Item 9a.

Insert the name, title, company/agency, address, telephone number, facsimile number, and e‑mail address (if available) of the program or project manager, quality assurance representative, or other customer technical representative who is most familiar with the quality of your work under the contract.

Item 9b.

Insert the name, title, company/agency, address, telephone number, facsimile number, and e‑mail address (if available) of the contracting officer, purchasing agent, or other customer contracting or purchasing representative who is most familiar with your work under the contract.

Item 9c.

Insert the name, title, company/agency, address, telephone number, facsimile number, and e‑mail address (if available) of (a) lead environmental regulator(s) or a State regulatory office director under whose authority environmental regulations would be enforced.

Item 10.

Insert names and phone numbers of consultants and partners/subcontractors used.

Item 11.

Insert the title of the project and/or contract.

Item 12.

Describe the nature and scope of the work. Describe the relevance of the work to the current acquisition and discuss performance. The objective is to show how the work that you did or are doing is similar in nature and scope to the work that is to be performed under the contract contemplated by the request for proposals. Describe any unusual circumstances of performance or problems that may be relevant to the work that is to be performed. Tell your side of the story of any conflicts with the customer concerning which they may make adverse remarks about your performance. Describe any actions that you have taken or plan to take to correct any shortcomings in your performance.

Item 13 Check the box which most accurately describes the current contract status.