C04f_(04) Exhibit A.pdf
PDF 628 KB Posted
- Solicitation number
- 12443926Q0248
- Issued by
-
Department of Agriculture Forest Service
About this file
This document is a template for Exhibit A: Contractor's Financial Information Sheet, a required federal contracting form used to collect and verify financial and organizational details about prospective contractors.
Section I requests general company information including legal name, business address, type of organization (sole proprietorship, corporation, LLC, joint venture, non-profit, etc.), taxpayer identification number, SAM Unique Entity Identifier, contact information, and description of products or services provided. It requires contractors to identify their business classification, such as large business, small business, small disadvantaged business, woman-owned small business, veteran-owned small business, HUB Zone, or other applicable designations. The form also requests ownership information for partners, principals, and other key individuals, and includes yes/no questions regarding bankruptcy history, judgments, liens, pending litigation, contingent liabilities, and discontinued business operations with outstanding debts.
Section II addresses government financial relationships and indebtedness, requiring disclosure of federal debt delinquency status, any amounts owed to the government for contracts or claims, current receipt of government financing (bonds, loans, advanced payments, progress payments), and any defaults or pending defaults on obligations to banks, financial institutions, suppliers, or other entities. All affirmative responses require submission of detailed supporting documentation.
View the file
Other files
| File | Type | Posted |
|---|---|---|
| C04_(00) Q and As for 12443926Q0248.pdf | ||
| C04g_(05) Exhibit B.pdf | ||
| C04b_(00) 12443926Q0248 SF1449 cont.pdf | ||
| C04c_(01) WD-IN.pdf | ||
| C04a_(00) 12443926Q0248 SF1449.pdf | ||
| C04d_(02) PWS.pdf | ||
| C04e_(03) Maps.pdf |
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Text version
Exhibit A: CONTRACTOR’S FINANCIAL 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 : 4. PHONE NUMBER 5. FAX NUMBER
6. SAM Unique Entity Identifier: 7. CELLPHONE NUMBER
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. EMERGING SMALL
BUSINESS
I. INDIAN SDB
B. SMALL BUSINESS F. VETERAN SMALL BUSINESS J. HUB ZONE - Also
C. SMALL DISADVANTAGED BUSINESS G. SERVICE DISABLED
VETERAN OWNED SMALL
BUSINESS
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, attach detailed information. 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”, attach detailed information.
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 attach detailed information.
https://sam.gov/content/duns-uei
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