Attachment_J.2.pdf

ATTACHMENT J-2 – STATEMENT OF FINANCIAL CAPABILITY

U.S. DEPARTMENT OF LABOR * Employment and Training Administration

RFP NO.

STATEMENT OF FINANCIAL CAPABILITY

(Insert the Name and Complete

Mailing Address of Offeror)

A. DATE LAST BALANCE

B. FINANCIAL CONDITION

(As of Date) _______________ 19____

(1) Cash .........................................................$___________________

(2) Current Assets .........................................$___________________

(3) Current Liabilities .....................................$___________________

(4) Net Worth ................................................$___________________

PERIOD COVERED (Month, Day, Year)

From

To

C. DATE FISCAL YEAR ENDS

(Month, Day, Year)

D. FINANCIAL ARRANGEMENTS TO FACILITATE PERFORMANCE DURING INITIAL PHASE OF CONTRACT ("X" appropriate box(es))

(1) Own Resources

(2) Bank credit

If "YES" complete

a. Name of Bank(s):

b. Amount

Yes No Yes No

(3) Other (If "YES", specify) Yes

No

E. IF ADVANCE PAYMENT IS INDICATED UNDER D(3) ABOVE, COMPLETE THE FOLLOWING:-

(1) Estimated Amount of Advance Payment

$_______________________ for ___________ months.

(2) The following advances from the Government are presently being received: (Complete Columns "a" thru "e" below)

AGENCY'S NAME AND ADDRESS

PERIOD

OF

CONTRACT

CONTRACT NO.

AMOUNT

ADVANCE

BANK

AGREEMENT WITH

(a) (b) (c) (d) (e)

ETA 8554 (Mar. 1981)

F. THE FOLLOWING IS A LIST OF CURRENT CONTRACTS WITH THIS OR ANY OTHER GOVERNMENT

AGENCIES.

(If additional space is needed, attach additional sheet(s))

ATTACHMENT J-2 – STATEMENT OF FINANCIAL CAPABILITY

AGENCY'S NAME, ADDRESS, AND

TELEPHONE NO.

CONTRACT NO.

AMOUNT

PERIOD OF

(1) (2) (3) (4)

G. IF OVERHEAD/INDIRECT COSTS ARE INCLUDED IN YOUR COST PROPOSAL, THE FOLLOWING DATA

WILL BE FURNISHED.

(1) Name and Address(es) of Cognizant Government

Audit Agency

(2) Name and Address of Government Auditor

Telephone Area Code

No. ( )

(3) Date Last Rate was Computed (Month, Day, Year)

(4) If no government audit agency computed and authorized the rate claimed, complete (a), (b), and (c) below.

(a) How it is computed?

(b) Who?

(c) Date (Mo., Day, Yr.)

ATTACH COMPUTATION DATA USED.

COMMENTS

CERTIFICATION:

I CERTIFY that to the best of my knowledge and belief the information contained herein is TRUE and CORRECT.

SIGNATURE

TYPED NAME AND TITLE

DATE (Mo., Day, Yr.)