C04_Past Performance Information Worksheet_12444126Q0032.pdf

1.Complete name of government agency, commercial firm or other organization

2. Complete address

3. Contract number or other reference 4. Date of contract

5. Date work was begun 6. Date work was completed

7. Initial contract price, estimated cost and fee, or target cost and profit or fee

8. Final amount invoiced or amount or amount invoiced to date

9 a. Technical point of contact (name, address, telephone no. and e-mail address)

9 b. Contracting or purchasing point of contact (name, address, telephone no. and e-mail address)

10. Location of work (country, state or province, county, city)

11. Description of contract work (Describe nature and scope). Attach an explanation of any performance problems or other conflicts with the customer. Describe any litigation pending, on-going, or completed. Use a continuation sheet, if necessary.

12. Current status of contract (choose one):

□ Work continuing, on schedule

□ Work continuing, behind schedule

□ Work completed, no further action pending or underway

□ Work completed, routine administrative action pending or underway

□ Work completed, claim negotiations pending or underway

□ Work completed, litigation pending or underway

□ Terminated for convenience

□ Terminated for default

□ Other (explain)

12444126Q0016 Attachment 4

Past Performance Reference Information Worksheet

Iouliaboxley Highlight

Instructions for Completing the Past Performance Reference Information Worksheet

Item 1. Insert the complete name of the customer, including parent organization, if any. Do not use acronyms.

Item 2. Insert the customer’s complete address, including both post office box and street address, if applicable.

Item 3. Insert the contract number or other contract reference used by the customer.

Item 4. Insert the date on which the contract came into existence.

Item 5. Insert the date on which you started to perform the work.

Item 6. Insert the date on which the customer agreed that the work was satisfactorily completed (including substantial completion), aside from any pending or on-going administrative actions, claims negotiations, or litigation.

Item 7. Insert the 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 8. 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 9a. Insert the name, title, address, telephone no., and e-mail address 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 referenced contract.

Item 9b. Insert the name, title, address, telephone no., and e-mail address of the contracting officer, purchasing agent, or other customer contracting or purchasing representative who is most familiar with your work under the contract.

Item 10. Insert the location(s) where the work was performed, including the country (if other than the United States) and the state or province, county (if applicable), and city.

Item 11. Describe the nature and scope of the work. The objective is to show how the work that you did or are doing is similar in nature and scope to the work that is to be performed under the contract contemplated by the request for proposals. Describe any unusual circumstances of performance or problems that may be relevant to the work that is to be performed. Tell your side of the story of any conflicts with the customer concerning which they may make adverse remarks about you performance. Describe any actions that you have taken or plan to take to correct any shortcomings in your performance. Describe any pending, on-going, or completed litigation.

Item 12. Insert a check mark in the block next to the choice which best describes the current status of the contract. If you select the “Other” block, provide a brief explanation.