Past_Performance_Information_Sheet.pdf

FA7037-16-R-0002

Addendum to FAR 52.212-1

PAST PERFORMANCE INFORMATION

Provide the information requested in this form for each contract/program being described. Provide frank, concise comments regarding your performance on the contracts you identify. Provide a separate completed form for each contract/program submitted. Limit the number of past efforts submitted and the length of each submission to the limitations set forth at paragraph 1.8 of the Addendum to FAR 52.212-1 of this solicitation.

A. Offeror Name (Company/Division):

CAGE Code:

DUNS Number:

(NOTE: If the company or division performing this effort is different than the offeror or the relevance of this effort to the instant acquisition is impacted by any company/corporate organizational change, note those changes).

B. Program Title:

C. Contract Specifics:

1. Contracting Agency or Customer :

2. Contract Number:

3. Contract Type:

4. Period of Performance:

5. Original Contract $ Value: (Do not include unexercised options)

6. Current Contract $ Value: (Do not include unexercised options)

7. If Amounts for 5 and 6 above are different, provide a brief description of the reason :

8. Estimated daily number of customers served:

D. Brief Description of Effort as __Prime or __Subcontractor

(Please indicate whether it was development and/or production, or other acquisition phase and highlight portions considered most relevant to current acquisition)

E. Completion Date:

1. Original date:

2. Current Schedule:

3. Estimate at Completion:

4. How Many Times Changed:

5. Primary Causes of Change:

F. Primary Customer Points of Contact: (For Government contracts, provide current information on all three individuals. For commercial contracts, provide points of contact fulfilling these same roles).

1. Program Manager and/or Name Site Manager:

Office:

Address:

Telephone:

FAX Number:

2. Contracting Officer Name:

3. Administrative Contracting Officer Name:

G. Address any technical (or other) area about this contract/program considered unique.

H. For each of the applicable subfactors under the Technical factor in the Addendum to FAR 52.212-2, illustrate how your experience on this program applies to each of the subfactors.

I. Specify, by name, any key individual(s) who participated in this program and are proposed to support this acquisition. Also, indicate their contractual roles for both acquisitions.

J. Include relevant information concerning your compliance with FAR 52.219-8, Utilization of Small Business

Concerns, on the contract you are submitting.

K. State Licensing Agency Only - Subcontracting Plan. Identify, in percentage terms, the planned versus achieved goals during contract performance. If goals were not met, please explain.

L. Describe the nature or portion of the work on the proposed effort to be performed by the business entity being reported here. Also, estimate the percentage of the total proposed effort to be performed by this entity and whether this entity will be performing as the prime, subcontractor, or a corporate division related to the prime (define relationship).