Attachment 6 - Contractor info.pdf

Attachment 6 Contractor Information Sheet

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 SDVOSB 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.