L_Appendix_C_5-_Past_Performance_Information_Form_v1.doc

SECTION L Appendix C Past Performance

Information Form

PAST PERFORMANCE INFORMATION FORM

Provide the information requested in this form for each contract/program (citation) 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 citations submitted and the length of each submission to the limitations set forth at paragraphs 2.8 and 5.3 of Clause L102, Information to Offerors and Instructions for Proposal Preparation, 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. Refer to the "Organizational Structure Change History" you provided as part of your Past Performance Volume).

B.

Contract 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.

D.

Brief Description of Effort as __Prime or __Subcontractor

Please indicate the nature of the service(s) provided and highlight which portion(s) of the effort considered relevant to the LSMA Technical subfactors and criteria.

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 Site Manager:

Name

Office

Address________________________________________

Telephone__________________

FAX Number_______________

2. Contracting Officer:

Name

Office

Address________________________________________

Telephone__________________

FAX Number_______________

3. Contracting Technical Representative:

Name Office ____________________ Address________________________________________

Telephone__________________

FAX Number_______________

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

H. For each of the applicable sub-factors under the Technical factor in Section M, illustrate how your experience on this program applies to that sub-factor.

I. Specify, by name, any key individual(s) who participated in this program and are proposed to support the instant 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.

Identify whether a subcontracting plan was required by the contract you are submitting. If one was required, 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).

LSMA L102 App C - Rev 0 – 3 Jan 2013