Exhibit B CONTRACTORS FINANCIAL INFORMATION SHEET FILLABLE.pdf

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USDA Forest Service - Arkansas OZARK NORTH Road Construction MATOC
Solicitation number
12445123R0005
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Road Construction Services

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 ID NUMBER: 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.

Solicitation Number:

Forest/State:

2 TYPE OF ORGANIZATION CHECK ONE1ANAME:
A Sole Propr etorship:
2 TYPE OF ORGANIZATION CHECK ONE1B STREET ADDRESS:
B General Partnersh p:
2 TYPE OF ORGANIZATION CHECK ONE1B STREET ADDRESS_2:
C Lim ted Partnership:
1C CITY:
1D STATE:
2 TYPE OF ORGANIZATION CHECK ONE1E ZIPPOSTAL:
2 TYPE OF ORGANIZATION CHECK ONE1E ZIPPOSTAL_2:
2 TYPE OF ORGANIZATION CHECK ONERow4:
I Other Spec fy:
3 TAXPAYER ID NUMBER:
4 PHONE NUMBER:
5 FAX NUMBER:
6 DUNS NUMBER:
7 CELLPHONE NUMBER:
8 KIND OF PRODUCT OR SERVICE PROVIDED:
9 EMAIL ADDRESS:
10 KIND OF BUSINESSSpec fy one block plus J f app cab eRow1:
A LARGE BUSINESS:
E EMERGING SMALL BUSINESS:
10 KIND OF BUSINESSSpec fy one block plus J f app cab eRow2:
B SMALL BUSINESS:
F VETERAN SMALL BUSINESS:
10 KIND OF BUSINESSSpec fy one block plus J f app cab eRow3:
C SMALL DISADVANTAGED BUSINESS:
10 KIND OF BUSINESSSpec fy one block plus J f app cab eRow4:
D WOMAN OWNED SMALL BUSINESS:
10 KIND OF BUSINESSSpec fy one block plus J f app cab eRow3_2:
K Other P ease Spec fy:
TITLE12:
TITLE13:
TITLE14:
TITLE15:
YesA Have youyour aff ates ever f ed for bankruptcy:
NoA Have youyour aff ates ever f ed for bankruptcy:
YesB Do you have any udgments ens pending suits:
NoB Do you have any udgments ens pending suits:
YesC Do you have any cont ngent abi t es:
NoC Do you have any cont ngent abi t es:
YesD Have youyour aff ates discont nued bus ness operat ons w th outstanding debts:
NoD Have youyour aff ates discont nued bus ness operat ons w th outstanding debts:
Yes17 Are you del nquent on any Federal Debt OMB C rcular 129:
No17 Are you del nquent on any Federal Debt OMB C rcular 129:
Yes18 Do you owe the Government for any contract or other c a ms:
No18 Do you owe the Government for any contract or other c a ms:
Yes19 Are you current y receiv ng Government F nanc ng Bonds Loans Advanced Payments Progress Payments Other:
No19 Are you current y receiv ng Government F nanc ng Bonds Loans Advanced Payments Progress Payments Other:
Yes19a Are you now n or pending Default on ANY Ob gat ons e Banks F nanc a Inst tut ons Suppl ers Other IF yes please attach deta ed nformat on:
No19a Are you now n or pending Default on ANY Ob gat ons e Banks F nanc a Inst tut ons Suppl ers Other IF yes please attach deta ed nformat on:
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