Form 9 - Questionnaire and Financial Statement~2.xlsx
XLSX spreadsheet 125 KB Posted
- Attached to
- ADA MENTOR PROTEGE PILOT PROGRAM
- Solicitation number
- B2727161
- Issued by
- Pennsylvania
About this file
This is a pre-qualification questionnaire and financial statement form issued by the City of Philadelphia for contractors seeking to qualify for public works projects under a Best Value procurement process. The form requires prospective bidders to provide comprehensive information about their business qualifications, experience, financial standing, and compliance history to be considered for the ADA Mentor Protege Pilot Program, which carries an engineer's estimate between $1,000,000 and $2,000,000 with a $200 bid processing fee. Contractors must submit completed questionnaires to the relevant City department by specified deadlines and provide detailed responses to all required sections, including years of business operation, construction experience as both prime and subcontractors, the largest dollar amounts of work completed in the past five years, descriptions of principal officers' construction experience, and references for completed projects similar in nature to the work being undertaken.
The questionnaire mandates disclosure of the contractor's financial position as of a date no more than six months old, including detailed accounting of current and long-term assets, liabilities, and equity, as well as available lines of credit. Applicants must report any prior performance issues with the City or other public and private owners, including defaults, terminations, failed completions, disqualifications, suspensions, or debarment actions. The City reserves the right to investigate any submitted information and disqualify bidders for misrepresentation, material changes in financial or corporate status, criminal convictions or indictments, undisclosed conflicts of interest, delinquent debts to the City, or pending litigation material to business operations. All information provided is held strictly confidential to the extent permitted by law, and submission of false information subjects contractors to penalties under Pennsylvania law.
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| City of Philadelphia |
| Best Value - Public Works |
| QUESTIONNAIRE AND FINANCIAL STATEMENT |
| FOR QUALIFYING APPLICANTS |
| *No bid will be accepted unless this questionnaire with all questions fully answered, is filed with the Department having jurisdiction over the work |
| proposed, on or before the date specified by the Procurement Department. |
| *All information provided by a Seller in this questionnaire shall be used by the City in determining |
and assessing a Seller's qualifications and responsibility in accordance with Chapter 17-100 of The Philadelphia Code.
| *The City reserves the right to investigate any statement made herein, by means of information included in but not limited to that |
| contained in this questionnaire. Any misrepresentation of fact, as determined by the City, may result in the disqualification of a seller. |
| *Any material change in the financial, corporate, or business status of a qualifying seller that occurs subsequent to the time |
| of submission of this questionnaire must be forwarded to the Procurement Commissioner immediately. Failure to do so, without |
limiting other remedies available to the City, may result in the disqualification of the seller from award(s) under this Program.
*All information on this questionnaire will be held strictly confidential, to the extent permitted by law.
| DATE SUBMITTED | BID NUMBER | CONTRACTOR LICENSE | |
| NUMBER | FEDERAL EIN NUMBER | CITY BUSINESS TAX IDENTIFICATION # |
SUBMITTED BY (PLEASE CIRCLE) INDIVIDUAL CORPORATION PARTNERSHIP
PRINCIPAL OFFICE ADDRESS
PRINCIPAL OFFICE TELEPHONE NUMBER PRINCIPAL OFFICE FAX NUMBER E-MAIL ADDRESS
| OEO REGISTRATION | |||||
| MBE o WBE o DSBE o | |||||
| CORPORATION | PARTNERSHIP | ||||
| DATE OF INCORPORATION | STATE | CAPITALIZATION | DATE OF ORGANIZATION | TYPE | |
| GENERAL LIMITED | |||||
| OFFICER | PARTNERS | ||||
| PRESIDENT | NAME | ||||
| ADDRESS | |||||
| VICE PRESIDENT | NAME | ||||
| ADDRESS | |||||
| SECRETARY | NAME | ||||
| ADDRESS | |||||
| TREASURER | NAME | ||||
| ADDRESS | |||||
| NAME | |||||
| ADDRESS |
| EXPERIENCE AND EQUIPMENT |
| 1. How many years has your organization been in business as a contractor under its present business name? |
On a separate sheet of paper, list all other business names under which your organization has been in business as a construction contractor?
| YEARS | |
| 2. How many years experience has your organization had as a prime contractor in the type of construction work for | |
| which you seek qualification? | YEARS |
| 3. How many years experience has your organization had as a subcontractor in the type of construction work for | |
| which you seek qualification? | YEARS |
| 4. State the largest dollar amount of work your organization has done in any single year during the last five years | |
| as (1) a general contractor $ (2) a subcontractor $ | |
| 5. On a separate sheet of paper, describe the construction experience of the principal officers and managers (including superintendents) of your |
organization. Include: name of the individual and postion/office, years of construction experience, type of work in which the individual has experience (including size of project worked on), names of organizations worked for and positions/ responsibilities held, union affiliations.
| 6. Has your organization within the last five years performed work for the City of Philadelphia that was not finally | |
| accepted by the City? | Please circle YES NO |
| If "YES", state the City contract number and project name and attach an explanation of the circumstances surrounding the non-acceptance. | |
| Has any officer, partner, or other person active in the management of your organization, within the last five years, been an officer, | |
| partner, manager, or sole proprietor of another organization which performed work for the City that was not finally accepted by the City? | |
| Please circle YES NO | |
| If "YES", state the name of the individual, the name and address of the organization, the City contract number and project name for the | |
| contract under which work was not finally accepted, and attach a detailed explanation of the circumstances surrounding the non-acceptance. | |
| 7. Has the City, within the last five years, declared your organization in default of a City contract or otherwise terminated the contract? | |
| Please circle YES NO | |
| If "YES", state the City contract number and project name and attach an explanation of the circumstances surrounding the declaration | |
| of default or termination. | |
| Has a commercial surety for your organization, within the last five years, been called upon to complete any work on a contract with the City? | |
| Please circle YES NO | |
| If "YES", state the City contract number and project name and a detailed explanation of the circumstances. | |
| Has any officer, partner, or other person active in the management of your organization, within the last five years, been an officer, partner | |
| manager, or sole proprietor of another organization whose commercial surety was called upon to complete any work on a contract with the | |
| City? | Please circle YES NO |
| If "YES", state the name of the individual, the name and address of the organization, the City contract number and project name for the | |
| contract the surety was called upon to complete, and attach an explanation of the circumstances. | |
| 8. Has any officer, partner, or other person active in the management of your organization, within the last five years, been an officer, partner, | |
| manager, or sole proprietor of another organization that was declared in default of a City contract or otherwise terminated, or that failed to | |
| complete a City Contract? | Please circle YES NO |
| If "YES", state the name of the individual, the name and address of the organization, the City contract number and project name for the | |
| contract defaulted or terminated and attach an explanation of the circumstances surrounding the declaration of default or termination. | |
| 9. Has your organization ever failed to complete any work under, or been declared in default of, a contract awarded to it by a public or private | |
| owner other than the City of Philadelphia? | Please circle YES NO |
| If "YES", attach a detailed explanation identifying the owner and bid/contract numbers (if applicable) for the project, stating whether the | |
| owner declared your organization in default of its contract, and describing the project, the type of work, the dates the work was started and | |
| stopped and the reasons the work was not completed. | |
| 10. Has any officer, partner, or other person active in the management of your organization ever been an officer, partner, manager, or sole | |
| proprietor of another organization that failed to complete or was declared in default of a contract for a public or private owner | |
| other than the City of Philadelphia? | Please circle YES NO |
| If "YES", state the name of the individual and attach a detailed explanation identifying the owner and bid/contract number (if applicable) | |
| stating whether the owner declared the organization in default of its contract, and describing the project, the type of work, the date the | |
| and stopped, the individual's role in the project, and the reasons the work was not completed. | |
| 11. Has any officer, partner, or other person active in the management of your organization within the last five years been disqualified, | |
| suspended, or debarred (under its present name or any other name) from bidding on public contracts, or removed from a bidders' list, by any | |
| state or federal agency, or by the City of Philadelphia? | Please circle YES NO |
| If "YES", state the agency that took such action, the date(s) of the action, the type of work to which the contract(s) applied, and the reasons | |
| stated by the agency for the action. | |
| 12. Has any commercial surety ever refused to furnish a performance or payment bond for your organization? | Please circle YES NO |
| If "YES", state the name and address of the surety, describe the contract for which the bond was refused (including the owner, date | |
| of contract, and type of work), and state the reasons for the refusal. Attach a letter from your surety company indicating your total bonding |
limit and current aggregate risk.
1. List any performance bonds that were called in the last five (5) years due to unsuccessful completion of the contract.
| 13. Has your organization or any officer, partner, or other person active in the management of your organization, or any shareholder holding | ||
| an equity interest of more than five percent, | ||
| 1. | ever been convicted of or pleaded guilty or nolo contendre to federal or state misdemeanor or felony charges (including but not | |
| limited to, charges related to public bidding law or the making of false statements)? | Please circle YES NO | |
| 2. | ever been refused coverage under any fidelity bond? | Please circle YES NO |
| Is your organization or any officer, partner, or other person active in the management of your organization, or any shareholder holding an | ||
| equity interest of more than five percent, | ||
| 1. | currently under indictment on federal or state misdemeanor or felony charges? | Please circle YES NO |
| 2. | currently the subject of a state or federal grand jury investigation or under notification by local, state or federal law | |
| enforcement authorities that they are the subject of any criminal investigation? | Please circle YES NO |
| If your answer to any of the foregoing questions is YES, attach a detailed description that includes the following: | |||
| * the nature of the conviction, plea, indictment, bond refusal, and/or grand jury or criminal investigation; | |||
| * the name of each individual who was the subject of such action; | |||
| * their position in your organization; | |||
| * the jurisdiction or entity taking the action; the date(s) the action was taken; the nature of the charges that were | |||
| the subject of the action; and all other circumstances relevant to the action. | |||
| 14. Has any officer, partner, director, shareholder, or other person active in the management of your organization been employed by the City | |||
| of Philadelphia, or been appointed to a political or other office of the City? | Please circle YES NO | ||
| If "YES" attach the following information: the name of the individual; position held with the City; the dates the employment or | |||
| appointment began and terminated. | |||
| 15. Identify, by name and business address, all organizations that are affiliates or subsidiaries of your organization, and state their | |||
| relationship to your organization. Attach separate sheet of paper as needed. | |||
| 16. Identify, by name and business address, any other organization and any individual (other than officers, partners, and managers of your | |||
| organization) that control or influence bidding by your organization. | |||
| 17. Identify all individuals and organizations, by name and business address, that hold a financial interest in your organization of ten percent | |||
| or more. | |||
| 18. Is your organization or any of its parent or subsidiary organizations currently indebted to the City of Philadelphia for any delinquent | |||
| City taxes, taxes collected by the City on behalf of the School District of Philadelphia, liens, judgments, fees or other debts? | Please circle YES NO | ||
| If YES, attach an explanation describing the nature and amount of the debt, lien, judgment, or fee; the dates of any notices from the City; | |||
| and any written agreement or payment plan with the City for its disposition. | |||
| 19. Have any liquidated damages or other penalties been imposed by the City on your organization? | Please circle YES NO | ||
| Have any liens, claims or stop notices been filed against your organization? | Please circle YES NO | ||
| If you answered YES to either of the above questions, please attach an explanation of details identifying the claimant and stating |
the grounds asserted by the claimant and stating the disposition.
20. Do you have any pending, contemplated or ongoing administrative or judicial proceedings material to your organization's business or finances including, but not limited to, any bankruptcy, litigation, consent orders or agreements with any state
| or federal regulatory agency issued to your organization? | Please circle YES NO | |
| If you answered YES, please attach an explanation, for each such proceeding, state the name of the case or proceeding, the parties |
involved, the nature of the claims involved, its current status and the final disposition, if any. Provide the same information for any officer, director, principal, or partner of Respondent's organization, and for any subcontractor Respondent plans to use to perform the services described in this RFP.
| If your organization has had construction contracts with the City of Philadelphia, provide the following information: | |||
| List all COMPLETED City of Philadelphia contracts within the last five years (attach additional paper as needed): | |||
| CONTRACT NUMBER | BID NUMBER | PROJECT DESCRIPTION | AMOUNT OF CONTRACT |
| List all INCOMPLETE contracts (City or otherwise) held by your organization at present. (Please attach additional sheets as needed.) | ||||
| CONTRACTING ENTITY | CONTRACT NO. | LOCATION | % COMPLETE | AMOUNT OF CONTRACT |
| List the largest projects that your organization has completed. | |||
| DOLLAR AMOUNT | DATE | CONTRACTING ENTITY | REFERENCES |
| Name | |||
| Phone Number | |||
| Name | |||
| Phone Number | |||
| Name | |||
| Phone Number | |||
| Name | |||
| Phone Number |
| List any projects that your organization has completed that are similar in nature to the project for which you are qualifying. | |||
| DOLLAR AMOUNT | DATE | CONTRACTING ENTITY | REFERENCES |
| Name | |||
| Phone Number | |||
| Name | |||
| Phone Number | |||
| Name | |||
| Phone Number | |||
| Name | |||
| Phone Number | |||
| Name | |||
| Phone Number | |||
| Name | |||
| Phone Number |
List any equipment that is owned by your organization that is available for the proposed work. (Please attach additional sheets as needed.)
| FINANCIAL POSITION AS OF: (Not over 6 months old) | ||
| ASSETS | LIABILITIES & EQUITY | |
| CURRENT ASSETS | CURRENT LIABILITIES | |
| Cash and cash equivalents | Lines of credit | |
| Short-term investments | Notes payable - current portion | |
| Accounts receivable | Accounts payable | |
| Allowance for doubtful accounts | ( ) | Accrued and withheld payroll taxes |
| Notes receivable | Accrued expenses | |
| Inventories | ||
| Prepaid expenses |
| Total Current Assets | Total Current Liabilities | ||
| PROPERTY AND EQUIPMENT | LONG-TERM LIABILITIES | ||
| Land | Notes payable | ||
| Buildings | |||
| Machinery and equipment | |||
| Trucks and automobiles | |||
| Office furniture and equipment | |||
| Assets under capital lease | Total Long-Term Liabilities | ||
| Total Liabilities | |||
| EQUITY | |||
| Total Property and Equipment | Common stock | ||
| Less accumulated depreciation | Additional paid-in capital | ||
| and amortization | ( ) | Less treasury stock | ( ) |
| Net Property and Equipment | Retained earnings | ||
| OTHER ASSETS | Partner's capital | ||
| Cash surrender value of officer's life insurance | Owner's equity | ||
| Loans against policies | |||
| Notes receivable | |||
| Organization costs (net) |
| Total Other Assets | Total Equity |
| TOTAL ASSETS | TOTAL LIABILITIES & EQUITY |
| Please provide the total dollar amount of all available lines of credit at your organization's disposal. |
| Please provide the total dollar amount of the balance of all available lines of credit at your organization's disposal. |
The City reserves the right to request any additional or clarifying information from Contractor at any time and Contractor is hereby notified that the City may contact any reference, financial institution or other agency identified by Contractor herein for further information. By submission of this pre-qualification statement, Contractor hereby acknowledges the City's right to revoke the qualification of Contractor at any time for reasons including, but not limited to, Contractor exceeding its capacity to perform work. Contractor hereby verifies that all information and documentation submitted herein is true and correct and Contractor acknowledges that the submission of false information by it is subject to the penalties of 18 Pa.C.S. Section 4904 relating to unsworn falsification to authorities.
FIRM OR CORPORATE NAME
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