Attachment J-05 Past Performance Information Form.pdf

SOURCE SELECTION INFORMATION - SEE FAR 3.104 (When Filled-In)

PAST PERFORMANCE INFORMATION FORM

1. Complete Name of Offeror

2. Contract Title and Location

3. Customer Name, Current Address, Telephone Number and E-mail

4. Contract Number and Type of Contract 5. Date of Contract Award

6. Date Work Commenced 7. Date the Work was Completed

8. Initial Contract Price /Estimated Cost and Fee 9. Final Amount Invoiced/Amount Invoiced to Date

10a. Technical Point of Contact (see instruction below) 10b. Contracting Point of Contact (see instruction below)

11a. Activity Title 11b. State if the Contract received a qualified, disclaimer, or adverse audit opinion over the past five years. Provide a copy of the auditor’s report (financial audits only).

12. Description of Work (Offerors may also explain how the work relates to effort to be acquired through this solicitation):

13. Self-Assessment of Past Performance Record. (Provide information on any problems encountered or adverse past performance information and your corrective actions. If more space is needed, please attach additional pages.)

14. Current Status of Contract (Choose One):

[ ] Work Continuing, on Schedule

[ ] Work Continuing, Behind Schedule

[ ] Work Completed, Litigation Pending or Underway

[ ] Work Completed, No Further Action Pending or Underway

[ ] Work Completed, Routine Administrative Action Pending or Underway

[ ] Work Completed, Claims Negotiations Pending or Underway

[ ] Terminated for Convenience

[ ] Terminated for Default

[ ] Other (explain)

Instructions for Completing the Past-Performance Information Form

Offerors shall submit Past-Performance Information Forms (Form) for three (3) contracts completed during the past five (5) years or from contracts currently in process. Only one (1) contract shall be described per form. A completed contract is one in which the services have been rendered or the end product(s) has been delivered; it has not necessarily been closed. If the offeror does not have three (3) references for Navy contracts or is not currently performing any

Navy contracts, it shall submit references for contracts with other DOD agencies, other Federal agencies, state and local governments, and/or private companies in that order of preference.

Item 1. Insert the name of the Offeror or team member, including parent organization, if any.

Do not use acronyms.

Item 2. Insert the contract title and address where work was performed. Do not use acronyms.

Item 3. Insert customer’s name, current address, including both post office box and street address (if applicable), telephone number, and e-mail.

Item 4. Insert any contract number, or other contract reference used by the customer, and the type of contract.

Item 5. Insert the date on which the contract was awarded.

Item 6. Insert the date on which work began.

Item 7. Insert the date on which the customer agreed that the work was satisfactorily completed (including substantial completion), aside from any pending or ongoing administrative actions, claims, negotiations, or litigation.

Item 8. Insert the initial contract price/estimated cost and fee, or target cost and profit or fee as it appeared in the original contract. If the contract included multiple, separately-priced items, add the individual item amounts and insert the total price, estimated cost and fee, or target cost and profit or fee.

Item 9. Insert the final sum of all invoices or the sum of all invoices to date, including agreed upon and disputed amounts, paid and awaiting payment.

Item 10a. Insert the name, title, company/agency, address, telephone number, and e-mail address (if available) of the program or project manager, quality assurance representative, or other customer technical representative who is most familiar with the quality of your work under the contract.

Item 10b. Insert the name, title, company/agency, address, telephone number, and e-mail address (if available) of the Contracting Officer, Purchasing Agent, or other customer contracting or purchasing representative who is most familiar with your work under the contract.

Item 11a. Provide the Activity Title, if different from Contract Title.

Item 11b. Identify if the contract received a qualified, disclaimer, or adverse audit opinion over the past five years. Provide a copy of the auditor’s report (financial audits only).

Item 12. Describe the nature and scope of the work as it relates to your proposed role in performing the effort to be acquired through this solicitation. The objective is for you to explain how the work you performed or are performing, is relevant (similar in scope, size in dollars, and complexity) to the Statement of Work (SOW) that is to be performed by you under the Contract. Provide a crosswalk to the SOW elements that are relevant to the work described in each Form. It is the Offeror’s responsibility to provide adequate information to enable the Government to obtain completed Past Performance Questionnaires from all referenced companies.

Item 13. Describe any unusual circumstances of performance or problems that may be relevant to the work that is to be performed and how those problems were addressed. Also describe any regulatory fines or Notices of Violation, if applicable. Tell your side of the story of any conflicts with the customer concerning adverse remarks about your performance. Describe any actions that you have taken or plan to take to correct any shortcomings in your performance. If the offeror requires additional space to discuss problems and corrective actions, up to three additional pages may be provided for this purpose only. Any pages over three will not be considered.

Item 14. Check appropriate box.