Financial_questionnaire_-_Responsibili_1

CONTRACTOR’S QUALIFICATIONS

AND FINANCIAL INFORMATION

SECTION I – GENERAL INFORMATION

2. TYPE OF ORGANIZATION (CHECK ONE) (Do not complete if already registered in CCR and ORCA.)

1A. NAME

A. Sole

Proprietorship

F. LLC

B. General Partnership

G. Joint Venture 1B. STREET ADDRESS

C. Limited

Partnership H. Non-Profit/Education

1C. CITY

1D. STATE 1E. ZIP/POSTAL D. Corporation I. Other: Specify

3. TAXPAYER ID NUMBER :

E. Subchapter S.

6. DUNS NUMBER

7. Reserved

8. KIND OF PRODUCT OR SERVICE PROVIDED:

9. PROJECT FOR WHICH THIS INFORMATION IS

SUBMITTED:

10. CENTRAL CONTRACTOR REGISTRATION (CCR) COMPLETED: [ ] YES [ ] NO [ ] IN PROCESS

11. OWNERSHIP INFORMATION – PARTNERS – PRINCIPALS - OTHERS

NAME TITLE

13.

14.

15.

16. Questions. If “Yes” to any below, provide detailed information in Section VI. Yes No A. Have you/your affiliates ever filed for bankruptcy?

B. Do you have any judgments, liens, pending suits?

C. Do you have any contingent liabilities?

D. Have you/your affiliates discontinued business operations with outstanding debts?

E. Do you have any other impacts on your financial resources needed to complete the performance of this contract?

SECTION II. GOVERNMENT FINANCIAL AID AND INDEBTNESS

If “Yes,” provide detailed information in Section VI. Yes No

17. Are you delinquent on any federal debt (OMB Circular 129)

18. Do you owe the Government for any contract or other claims?

19. Are you currently receiving Government financing? (bonds, loans, advanced payments, progress payments, other)

20. Are you now in or pending default on ANY obligations (i.e. banks, financial institutions, suppliers, other)?

SECTION III – REFERENCES– CURRENT CONTRACTS INFORMATION

21. CONTRACT 1 22. CONTRACT 2

LOCATION LOCATION

OWNER'S NAME OWNER'S NAME

CONTACT PERSON CONTACT PERSON

TELEPHONE TELEPHONE

FAX FAX

ADDRESS (City, State, Zip/Postal) ADDRESS (City, State, Zip/Postal)

TYPE OF WORK TYPE OF WORK

CONTRACT AMOUNT CONTRACT AMOUNT

% COMPLETE % COMPLETE

ESTIMATED COMPLETION DATE ESTIMATED COMPLETION DATE

23. CONTRACT 3 24. CONTRACT 4

LOCATION LOCATION

OWNER'S NAME OWNER'S NAME

CONTACT PERSON CONTACT PERSON

TELEPHONE TELEPHONE

FAX FAX

ADDRESS (City, State, Zip/Postal) ADDRESS (City, State, Zip/Postal)

TYPE OF WORK TYPE OF WORK

CONTRACT AMOUNT CONTRACT AMOUNT

% COMPLETE % COMPLETE

ESTIMATED COMPLETION DATE ESTIMATED COMPLETION DATE

25. Is your current workload such that successful completion of any of these contracts is in danger? Are any of these contracts behind schedule? Will your current workload and demands on your managerial and administrative organization and on your physical resources have an impact on the successful completion of the contract for which you are being considered? (If yes to any of these questions, explain in Section VI.) [ ] Yes [ ] No

SECTION IV – REFERENCES - PAST PERFORMANCE – COMPLETED CONTRACTS

INFORMATION

26. CONTRACT 1 27. CONTRACT 2

LOCATION LOCATION

OWNER'S NAME OWNER'S NAME

CONTACT PERSON CONTACT PERSON

TELEPHONE TELEPHONE

FAX FAX

ADDRESS (City, State, Zip/Postal) ADDRESS (City, State, Zip/Postal)

TYPE OF WORK TYPE OF WORK

CONTRACT AMOUNT (AWARD) CONTRACT AMOUNT (AWARD)

CONTRACT AMOUNT (FINAL) CONTRACT AMOUNT (FINAL)

COMPLETION DATE COMPLETION DATE

28. CONTRACT 3 29. CONTRACT 4

LOCATION LOCATION

OWNER'S NAME OWNER'S NAME

CONTACT PERSON CONTACT PERSON

TELEPHONE TELEPHONE

FAX FAX

ADDRESS (City, State, Zip/Postal) ADDRESS (City, State, Zip/Postal)

TYPE OF WORK TYPE OF WORK

CONTRACT AMOUNT (AWARD) CONTRACT AMOUNT (AWARD)

CONTRACT AMOUNT (FINAL) CONTRACT AMOUNT (FINAL)

COMPLETION DATE COMPLETION DATE

30. Have you ever been involved in a contract that was terminated for default? (If yes, explain in Section VI.)

[ ] Yes [ ] No

SECTION V – BUSINESS ETHICS

If “Yes,” provide detailed information in Section VI. Yes No

31. Are there currently any debarment proceedings involving your firm, any affiliate or partner, or any principal or officer of your firm?

32. Are there currently any legal proceedings against your firm, any affiliate or partner, or any principal or officer of your firm, involving any back wages, incomplete or unacceptable work, or other areas of dispute resulting from previous or current contracts?

SECTION VI - REMARKS

REMARKS – Cite those sections of the form relating to your remarks. If additional space is needed, please use blank pages.

Refer to the questions being addressed.

CERTIFICATION

By signing and submitting this form, you are giving permission to the Contracting Officer to use this and all related information to establish your financial capability to perform the contract for which you are being considered, to determine the acceptability of your references in evaluating past performance, and to make a declaration of your responsibility as required by the Federal Acquisition Regulation.

This is a declaration made to an agent of the United States Government. Title 18, United States Code, Section 1001, makes it a crime knowingly and willfully to make any materially false, fictitious or fraudulent statement or representation in any matter within the jurisdiction of the executive, legislative or judicial branch of the United States.

Violators shall be fined under this title or imprisoned not more than 5 years, or both.

Signed: _____________________________________ Title: _______________________________________

Printed or Typed Name: _________________________________ Date signed: ______________________