CTR_INFORMATION.pdf
PDF 23 KB Posted
- Solicitation number
- AG-52B1-S-15-0007
About this file
Contractor Financial Information
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Text version
CONTRACTOR’S FINANCIAL INFORMATION
SECTION 1 – GENERAL INFORMATION
1A.NAME 2. TYPE OF ORGANIZATION (CHECK ONE)
A. Sole Proprietorship
F. LLC
1B. STREET ADDRESS B. General Partnership
G. Joint Venture
C. Limited Partnership
H. Non- Profit/Education
1C. CITY 1D.
STATE
1E.
ZIP/POSTAL
D. Corporation i. Other: Specify E. Subchapter S.
3. TAXPAYER ID NUMBER :
6. DUNS NUMBER 7. VENDOR EXPRESS NUMBER: (FS VENDORS)
8. KIND OF PRODUCT OR SERVICE PROVIDED:
10. KIND OF BUSINESS- Specify one block (plus “J” if applicable)
A. LARGE BUSINESS E. WOMAN OWNED SDB I. INDIAN SDB
B. SMALL BUSINESS F. VETERN SMALL
BUSINESS
J. HUB ZONE - Also
C. SMALL DISADVANTAGED
BUSINESS
G. VETERAN SDB K. Other: Please Specify
D. WOMAN OWNED SMALL
BUSINESS
H. INDIAN SMALL
BUSINESS
11. OWNERSHIP INFORMATION – PARTNERS – PRINCIPALS - OTHERS
NAME TITLE
13.
14.
15.
16. Questions. If “Yes” to any below, provide detailed information in section vii, remarks. 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
SECTION II. GOVERNMENT FINANCIAL AID AND INDEBTNESS
If “Yes” provide detailed information in Section VII, remarks.
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) 19a. Are you now in or pending Default on ANY Obligations (i.e. Banks, Financial Institutions, Suppliers, Other)? IF yes please provide detailed information in Section VII remarks.
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