Attachment 5 Contractors Financial Info.docx

DOCX document 24 KB Posted

Attached to
Delta Work Center Flood Repairs Federal contract opportunity
Solicitation number
12445121Q0010
Issued by
Department of Agriculture Forest Service R8-Southern Region

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Other files attached to Delta Work Center Flood Repairs, newest first.
File Type Posted
Sol_12445121Q0010_Amd_0001.pdf PDF
Sol_12445121Q0010.pdf PDF
Attachment 1 Delta Work Center Repairs - Plans.pdf PDF
Attachment 3 Designation of Representative.pdf PDF
Attachment 2_Notice_Noncompliance.pdf PDF
Attachment 4 Experience Questionaire.docx DOCX document
Attachment 6 Wage Determination.pdf PDF

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Road Maintenance IDIQ 12447U20R0002 National Forests in Mississippi

ATTACHMENT 5

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 :
4. PHONE NUMBER
5. FAX NUMBER
6. DUNS NUMBER:
7. FFIS VENDOR CODE: (FS VENDORS)
8. KIND OF PRODUCT OR SERVICE PROVIDED:
9. EMAIL ADDRESS

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. VETERAN 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 INDEBTEDNESS

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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