Attachment_J-2.pdf

STATEMENT OF FINANCIAL CAPABILITY

=(Insert the Name and Complete Mailing Address of Offeror)

RFP NO.

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

A. DATE LAST BALANCE

WAS PREPARED

B. FINANCIAL CONDITION

(as of Date) 19

PERIOD COVERED (Month, Day, Year) (1) Cash . . . . . . . . . . . . . . . . . . . . . . . . . $

From To (2) Current Assets . . . . . . . . . . . . . . . . . . $

FILED WITH (3) Current Liabilities . . . . . . . . . . . . . . . . $

C. DATE FISCAL YEAR ENDS

(Month, Day, Year) <

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

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

(1) Own Resources

~ Yes ~ No

(2) Bank Credit

~ Yes ~ No

If “YES,” complete

a. Name of Bank (1):

b, Amount

(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

OF

ADVANCE

BANK

AGREEMENT WITH

(a) (g) (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))

AGENCY'S NAME, ADDRESS, AND TELEPHONE NO. CONTRACT NO.

AMOUNT

OF

CONTRACT

PERIOD OF CONTRACT

(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 and Negotiated _______________________________________________

(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.)

ETA 8554 (Mar 1981)