B5-Contractor's Qualification Statement.pdf

12/03/2012 Appendix 66: Contractor’s Qualification Statement

Appendix HOUSING REHABILITATION CONTRACTOR’S

QUALIFICATION STATEMENT 66

Please attach a copy of contractor’s license, insurance policy, and EPA Certification.

All questions must be answered in full. Additional sheets for clarification of answers or additional information must be attached. This statement must be notarized.

1. Name, address, phone number, contractor license #, and IRS number (or last 4 digits of owner's social security #) of company. Include DUNS and UEID if known.

2. List company’s owner and principal officer and date and place organized.

3. Describe general character of work performed.

4. List any work awarded that failed to be completed or contracts defaulted on. Note where and why.

5. List three most important recent contracts over $10,000. State the owner, work, approximate cost, place, date started and date completed.

1._______________________________________________________ $ ________ ________________________________________ From ________ To _________ 2._______________________________________________________ $ ________ ________________________________________ From ________ To _________ 3._______________________________________________________ $ ________ ________________________________________ From ________ To _________

6. List the contracts upon which you are currently working. State the owner, location, approximate cost, and estimated date of completion.

7. List three material suppliers and amount of credit available.

1._____________________________________________ $ ____________ 2._____________________________________________ $ ____________ 3._____________________________________________ $ ____________

8. List bank references and amount of credit available.

1._____________________________________________ $ ____________ 2._____________________________________________ $ ____________

9. List insurance coverage and amount. Please attach copy of insurance policy.

Liability-Property: _____________________________ $____________ Liability-Personal Injury: ________________________ $____________ Vehicle and Equipment: _________________________ $____________ Other: __________________ : __________________ $____________ (identify)

10. List subcontractors utilized. State name, address, specialty, subcontractor license #, and years of experience.

1. Name:

Address:

Specialty:

License # Years of Experience

2. Name:

Address:

Specialty:

License # Years of Experience

3. Name:

Address:

Specialty:

License # Years of Experience

11. Provide a general description of the experience of the company and its key personnel.

12. Number of current full-time employees _______ Number employed at highest level in past twelve months _______

13. Are you on any list of debarred contractors maintained by the U.S. Department of

Labor, U.S. Department of Housing & Urban Development, or Virginia Department of Highways? YES NO

14. All contractors and subcontractors, including electricians, must have the EPA required Renovate, Repair and Painting certification (RRP) in order to be considered for work on houses constructed before 1978 funded under this program.

Does your company carry this certification?

YES NO If yes, complete the Company/Employee Record.

If not, someone from your company will be required to attend the training before work can begin on a project site and. Do you need information about lead training and certification classes?

YES NO

The undersigned hereby authorizes and requests any person, firm or Corporation to furnish any information requested by __________________________________ in verification of the recitals comprising this statement of contractor's qualifications:

Contractor:

By:

Title:

Date:

BY: __________________________________________ DATE: ,

City/County/Town of ______________________________, Commonwealth of Virginia

_______________________________ being duly sworn deposes and says that he/she is ________________________ of and that the answers to the foregoing questions and all statements therein contained are true and correct.

My commission expires: ________________________.

Given under my hand this ______day of ____________, 20 .

Notary Public Registration Number

LEAD BASED PAINT RELATED TRAINING AND CERTIFICATIONS

COMPANY AND EMPLOYEE RECORD

Contractor’s Name: ________________________________ Date: ____________

Company/Employee Name Training/Certification Type and Certificate Number

RRP – Certificate #

Note: Each contractor must at a minimum have EPA Certification in “Renovate, Repair and Painting” as a firm and at least one individual Certified Renovator assigned to the project.