Attachment 4 - Past Performance Reference Sheet.pdf

FA485524R0007

Attachment 4

Past Performance Reference Sheet Provide the information requested in this form for each one of the present or past contracts identified as recent and relevant for this solicitation. Provide a separate completed form for each reference.

A. Current Offeror (Company/Division):

Cage Code:

DUNS Number:

Additional Information: (If Present/Past Performance is for major subcontractor, please provide Company Name of subcontractor and annotate in this block “Subcontractor”. If the company or division performing this present or past effort is different from the current Offeror, note this fact in the space provide.)

B. Program Title:

C. Contract Specifics

1. Customer Name:

2. Customer Address and Phone No.

3. Contract Number and all applicable Order Numbers (i.e. Task Order, Delivery, Order, etc.):

4. Type of Contract

5. Period of Performance

6. Performed Work as: □ Prime Contractor □ Subcontractor

□ Teaming Arrangement □ Joint Venture

7. Percentage/Portion of Work Performed:

8. Initial Contract Price/Cost $

9. Final Amount Invoice/Amount Invoice to Date: $

10. Reason for Change(s) in Value:

11. Original Completion Date:

12. Current Scheduled Completion Date:

13. Number and Reason for Change(s) in Schedule:

D. Description of Effort as Prime or Subcontractor.

E. Describe how the work under this contract relates to this requirement.

F. Describe compliance with contract terms and conditions

G. Self-assessment of past performance record. Provide information of any problems encountered and your corrective actions.

Attachment 4

POINTS OF CONTACT

Contracting Officer Contract Adminstrator Quality Assurance

Name:

Office:

Email:

Telephone:

Other (specify):

Name:

Office:

Email:

Telephone: