F1A02 Exhibit 15 Financial Statement.pdf

Contract #_F1A02____ Financial Project # 448210-1-52-01__

FCO Non-Technical Specifications (Revised 8/31/2016) Page 53 of 62

(Exhibit 15)

CONTRACTOR’S EXPERIENCE QUESTIONNAIRE

AND FINANCIAL STATEMENT

The information listed in the Experience Questionnaire and Contractor's Financial Statement Forms is required to be filed with soliciting agencies prior to award of any contract. In order to expedite the processing of contracts, please complete the enclosed forms in accordance with these instructions.

The bidder is required to complete all the attached forms. If the bidder is a Joint Venture, then each Corporation, Partnership, or Individual that is a party to the Joint Venture must individually complete each form.

All references to "fiscal year" in this questionnaire will mean the fiscal year of the bidder filing this form.

PAGE 2 OF 9:

Project Title - Indicate title of project as shown in the specifications.

Location - Project location as shown in the specifications.

Trades or Trades Being Bid – Enter the appropriate code number(s) from the list below which represent the trade(s) for which you are qualified to bid:

Trade Code Number

Building Construction 1 Electrical 2 Elevator 3 Food Service 4 Heating, Ventilating & Air Conditioning 5 Laboratory Equipment 6 Landscaping 7 Plumbing 8 Power Plants (Boilers, Equipment & Piping) 9 Refrigeration 10 Roofing 11 Sanitary (Sewage Treatment Plants, Pumping Stations, etc.) 12 Other 13

PAGES 3 & 4 OF 9:

Complete in accordance with form.

PAGE 5 OF 9:

Section 53 - Under "c", list previous business name or names and the number of years you have done business under these names within the past 10 years.

PAGE 6 OF 9:

Section 54 - From your present payroll indicate the number of individuals in each category in the "Current" column.

Estimate the maximum and minimum number of employees over the previous 3 fiscal years in each category.

PAGES 7 & 8 OF 9:

Complete in accordance with form.

1) In Section 62, Column C insert "S" if a subcontractor or "P" if a prime-contractor. The balance of this section is to be completed in accordance with form.

2) Billings for 3 fiscal years - insert year and amount.

3) Work in Progress at the end of the past 3 fiscal years - same as above.

FCO Non-Technical Specifications (Revised 8/31/2016) Page 54 of 62

(Exhibit 15)

CONTRACTOR’S EXPERIENCE QUESTIONNAIRE

AND FINANCIAL STATEMENT

Project Name: Generator Installation at Heartland Operations Center - Arcadia

Project Location: 1190 W. Oak Street, Arcadia, FL 34266

Insert code number of trade or trades for which you are qualified to bid on the basis of previous experience in accordance with attached detailed instructions, each on the respective line shown below:

1.

2.

3. Is your organization currently pre-qualified with any governmental agency?

If so, please list.

4. Have you, in the previous five years, been denied a contract award on which you submitted the low bid in competitive bidding, or been refused prequalification?

If so, please list and describe:

5. Submitted by: _________________________________________________ Date:

Address:

6. Check appropriate box:

!$A Corporation ! A Co-Partnership ! An Individual ! A Joint Venture

The Contractor acknowledges that this Experience Questionnaire and Financial Statement is made for the express purpose of inducing the Owner to whom it is submitted to award a contract to the contractor, and further the Contractor acknowledges that the agency may at its discretion, by means which the Owner may choose, determine the truth and accuracy of all statements made by the Contractor herein.

FCO Non-Technical Specifications (Revised 8/31/2016) Page 55 of 62

(Exhibit 15)

SECTION "A" - FINANCIAL STATEMENT

As of (Date)

ASSETS

7. CASH* $

ACCOUNTS RECEIVABLE

8. From Government Contracts Completed

9. From Non-Government Contracts Completed

10. Claims included in 8 and 9 not yet approved or in litigation $

11. From Government Contracts in Process

12. From Non-Government Contracts in Process

13. Claims included in 11 and 12 not yet approved or in litigation

14. Retainage included in 11 and 12

15. Other** (list)

NOTES RECEIVABLE

16. Due within 90 days**

17. Due after 90 days**

INVESTMENTS

18. Listed securities - present market value

19. Unlisted securities - present value

BID DEPOSITS

20. Recoverable within 90 days

21. Recoverable after 90 days

ACCRUED INTEREST

22. Receivable on notes

23. Receivable on Investments

24. Other (list)

25. REAL ESTATE (Book Value or Market, whichever is less)

26. INVENTORIES (Not included in receivable billing & at present value)

27. EQUIPMENT-NET BOOK VALUE

(Supply list by cost, depreciation, net book value)

OTHER ASSETS

28. Contract Costs in excess of Billings $

29. Cash Surrender Value of Life Insurance

30. Receivables from Officers and Employees

FCO Non-Technical Specifications (Revised 8/31/2016) Page 56 of 62

(Exhibit 15)

SECTION "A" - FINANCIAL STATEMENT

31. Other (list)

32. TOTAL ASSETS $

*Do not include deposits for bids or other Guarantees **Do not include receivables from officers and employees

ACCOUNTS PAYABLE

33. Due within 1 year ______________

34. Due after 1 year

NOTES PAYABLE

35. Due within 1 year

36. Due after 1 year

37. Officers and Employees

38. TAXES PAYABLE

39. ACCRUED AND ACTUAL PAYROLL PAYABLE

40. MORTGAGES PAYABLE

OTHER LIABILITIES

41. Federal Income Tax Provision

42. Deferred Income

43. Other (list)

NET WORTH

44. (If individual proprietorship or partnership)

CAPITAL STOCK

45. Common Issued and Outstanding

46. Preferred Issued and Outstanding

47. Treasury Stock $

CAPITAL SURPLUS

48. Earned Surplus Prior Years

49. Earned Surplus Current Year

50. TOTAL LIABILITIES AND NET WORTH $

NOTE: IF ADDITIONAL SPACE IS REQUIRED, PLEASE NOTE AND ATTACH SCHEDULE TO STATEMENT

51. Dated this day of , YR .

Name of Organization

By:

Signature/Title

FCO Non-Technical Specifications (Revised 8/31/2016) Page 57 of 62

(Exhibit 15)

SECTION 'B' - EXPERIENCE QUESTIONNAIRE

52. If a Corporation, answer this: If a Partnership or Individual Proprietorship, answer this:

Date of incorporation Date of organization

In what State If a partnership, state whether partnership is general, limited association

Name of Officers:

President Name and Address of Partners:

Vice President

Vice President

Secretary

Treasurer

53. a. How many years has your organization been in the construction business?

b. How many years under your present business name?

c. How many years under previous business name? (List other names)

SUBSIDIARY OR AFFILIATED COMPANIES IN WHICH PRINCIPALS HAVE FINANCIAL INTEREST

EXPLAIN IN DETAIL THE

NAME AND ADDRESS OF SUBSIDIARY PRINCIPAL'S INTEREST IN THIS

OR AFFILIATED COMPANIES COMPANY AND NATURE OF

BUSINESS

FCO Non-Technical Specifications (Revised 8/31/2016) Page 58 of 62

(Exhibit 15)

NUMBER OF FULL TIME PERSONNEL WITHIN YOUR ORGANIZATION

54. a. Clerical Personnel

b. Engineers & Architects

c. Supervisors, Foremen, or Superintendents

d. Skilled Employees including Technicians

e. Unskilled Employees

f. Estimators

g. Total number of full time personnel

55. WHAT IS THE CONSTRUCTION EXPERIENCE OF THE PRINCIPALS AND SUPERVISORY PERSONNEL OF YOUR ORGANIZATION? (Asterisk any personnel likely to be assigned to project being bid.)

PRINCIPAL'S TITLE YEARS OF IN WHAT CAPACITY

NAME CONSTRUCTION AND WITH WHOM

EXPERIENCE

56. SUPERVISORY TITLE YEARS OF IN WHAT CAPACITY

PERSONNEL CONSTRUCTION AND WITH WHOM

EXPERIENCE

57. Within the previous 3 fiscal years has your organization or predecessor organizations ever failed to complete a project? If so, state name of organization and reason thereof.

58. Within the previous 3 fiscal years has your organization been involved in litigation? . If so, please list and explain nature and current status.

FCO Non-Technical Specifications (Revised 8/31/2016) Page 59 of 62

(Exhibit 15)

NUMBER OF FULL TIME PERSONNEL WITHIN YOUR ORGANIZATION

59. List all contracts completed by your organization in the previous 3 fiscal years. (If more than 10, list the 10 most recently completed.

NAME OF

OWNER

(A)

NAME,

LOCATION &

DESCRIPTION

OF PROJECT

(B)

TYPE OF

WORK

NAME OF

DESIGN

ARCHITECT

AND/OR DESIGN

ENGINEER

(C)

ORIGINAL

CONTRACT

PRICE COMPLETION DATES:

(D)

FINAL

CONTRACT

PRICE

(E)

ORIG.

(F)

REVISED

(G)

ACTUAL

FCO Non-Technical Specifications (Revised 8/31/2016) Page 60 of 62

(Exhibit 15)

NUMBER OF FULL TIME PERSONNEL WITHIN YOUR ORGANIZATION

With reference to all contracts completed by your organization in the previous fiscal years, as listed on Exhibit 3, Page 7 of 9, Item #59, answer the following questions:

60. Explain differences in original contract price and in completion dates, if any.

61. Were there any liquidated damages, penalties, liens, defaults, or cancellations imposed or filed against your organization? If so, list the name and location of the project, as shown in Column A, explain.

FCO Non-Technical Specifications (Revised 8/31/2016) Page 61 of 62

(Exhibit 15)

STATUS OF UNCOMPLETED CONTRACTS

As of: (date)

62. Give full information about all of your present contracts. In Column C insert "S" if a subcontractor or "P" if a prime contractor, whether in progress or awarded but not yet begun; and regardless of with whom contracted.

A B C D E

Project Description Location & Owner

Design Architect And/Or Design

Engineer

Total Amount of Your Contract (Or

Subcontract)

Amount In Column C Sublet

To Others

Uncompleted Amount of Contract

Total

COMPLETE THE FOLLOWING:

Net Total Billings for Previous 3 Fiscal years: Average Backlog for Previous 3 Fiscal Years: (Estimated total value of uncompleted work on outstanding contract)

YR $ YR $

YR $ YR $

YR $ YR $