GSA527_-_Contractor's_Qualifications_and_Financial_Information.docx

DOCX document 55 KB Posted Jul 10, 2014

Attached to: Fine Arts Services
Solicitation number: GS-00P-14-CY-D-0055
Issued by: General Services Administration Public Buildings Service Central Office Acquisition Services Division

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GSA527 - Contractor's Qualifications and Financial Information

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GENERAL SERVICES ADMINISTRATION

GSA

FORM

(REV. 3-99)

)CONTRACTOR'S QUALIFICATIONS AND FINANCIAL INFORMATION

	OMB No.: 3090-0007
Expires:	8/31/2015

Public reporting burden for this collection of information is estimated to average 2.5 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the Financial Information Control Division (BCD), Office of Finance, GSA, Washington, DC 20405; and to the Office of Management and Budget, Paperwork Reduction Project (3090-0007), Washington, DC 20503.

SECTION I - GENERAL INFORMATION

1A. NAME

2. TYPE OF ORGANIZATION (Check one)

A. SOLE PROPRIETORSHIP

F. LIMITED LIABILITY COMPANY

1B. STREET ADDRESS

B. GENERAL PARTNERSHIP

G. JOINT VENTURE

C. LIMITED PARTNERSHIP

H. TRUST

1C. CITY

1D. STATE

1E. ZIP CODE

D. CORPORATION

I. OTHER (Specify below)

E. SUBCHAPTER S CORPORATION

3. TAXPAYER ID NUMBER

4. DATE ORGANIZATION ESTABLISHED

5. STATE OF INCORPORATION

6. TRADE STYLE NAME (Provide a copy of filing)

7. KIND OF PRODUCT OR SERVICE PROVIDED

8. FORMER BUSINESS NAME

10. INVENTORY VALUATION METHOD

A. LIFO

C. AVERAGE COST

9. KIND OF BUSINESS

A. MANUFACTURER

D. RETAILER

B. FIFO

D. OTHER (Specify)

B. CONTRACTOR

E. OTHER (Specify)

C. WHOLESALER

11. OWNERSHIP INFORMATION-PARTNERS-PRINCIPAL STOCKHOLDERS-OTHERS

NAME

TITLE

(If partner, state G(General) or L(Limited) in column)

% BUSINESS

OWNED

ACTUAL TITLE

G OR L

12. PARENT COMPANY (If applicable)

13. IF 'YES' TO ANY QUESTION BELOW, PROVIDE DETAILED

INFORMATION IN SECTION VIII, REMARKS

YES

A. NAME

A. HAVE YOU, OR ANY OF YOUR AFFILIATES EVER FILED FOR BANKRUPTCY?

B. DO YOU HAVE ANY JUDGMENTS, LIENS, OR PENDING SUITS?

B. CITY

C. STATE

C. DO YOU HAVE ANY CONTINGENT LIABILITIES?

D. HAVE YOU OR ANY OF YOUR AFFILIATES DISC. BUSINESS OPER. W/OUTSTANDING DEBTS?

15B. AMOUNT OF DELINQUENCY ($)

15A. AGENCY INVOLVED WITH DELINQUENCY

(Go to Section III

E. OTHER

(Specify)

14A. ARE YOU DELINQUENT ON ANY FEDERAL DEBT (OMB CIRCULAR A-129)

(If "Yes", provide detailed information, Section VIII, Remarks)

ADVANCED PAYMENTS

PROGRESS PAYMENTS

YES

IF 'YES', COMPLETE THE ITEMS BELOW

BALANCE

CLAIM AMOUNT

AGENCY

PAYMENT

14B. DO YOU OWE THE GOVERNMENT FOR ANY CONTRACT OR OTHER CLAIMS?

YES

MATURITY

16. ARE YOU CURRENTLY RECEIVING GOVERNMENT FINANCING?

TYPE OF FINANCING

INDUSTRIAL REVENUE BONDS

GUARANTEED LOANS

GOVERNMENT AGENCY INVOLVED

17. COMPLETE ITEMS BELOW IF APPLICABLE

AUTHORIZED ($)

IN USE ($)

)SECTION II - GOVERNMENT FINANCIAL AID AND INDEBTEDNESS

GSA

FORM

(REV.3-99)

)SECTION III - FINANCIAL STATEMENTS

Prepared Financial Statements with notes may be provided in lieu of completing Section III

	When financial statements are prepared or certified by independent accountants and transcribed to this form, please furnish the name and address of accountant of accounting firm.
	18. ARE YOU THE INCUMBENT CONTRACTOR FOR THIS SOLICITATION?
YES	NO

19A. NAME

20. IF TRANSCRIBED STATEMENTS DIFFER FROM INDEPENDENT ACCOUNTANT'S,

PLEASE DESCRIBE ADJUSTMENT IN SECTION VII, REMARKS. ALL OF THE

LISTED FIGURES ARE:

19B. STREET ADDRESS

19C.

ACTUAL

U.S. DOLLARS

19D. CITY

19E. STATE

19F. ZIP CODE

IN THOUSANDS

FOREIGN CURRENCY (Specify)

IN MILLIONS

21. BALANCE SHEET AS OF (Month, Day, Year)

22. FISCAL YEAR ENDS (Month, Day, Year)

23. PREPARED STMTS. ARE ATTACHED

24. ASSETS

25. LIABILITIES AND NET WORTH

A. Current Assets

A. Current Liabilities

Cash

Accounts payable

Short Term cash investments

Notes payable (current)

Accounts receivable, less allowance for doubtful accounts of $

Current portion of long term debt

Accrued expenses

Inventories

Accrued taxes on income/excess profits

Other current assets (Itemize below)

Other current liabilities (Itemize)

Total Current Assets

Total Current Liabilities

B. Property, Plant and Equipment

B. Other Liabilities

Land

Mortgages

Buildings and equipment

Bonds

Leasehold improvements

Deferred income taxes

Less accumulated depreciation and amortization

Other long term debt

Total Other Liabilities

Total Property, Plant and Equipment

C. Other Assets

Total Liabilities

Investments in and advance to affiliated company

C. Minority Interest in Subsidiary

Goodwill, less amortization

D. Net Worth

Due from officer, employee

Preferred stock

Other (Itemize)

Common stock

Additional paid-in capital

Retained earnings/owner's equity

Less, Treasury stock

Total Other Assets

Total Net Worth

D. TOTAL ASSETS

E. TOTAL LIABILITIES AND NET WORTH

SECTION IV - INCOME STATEMENT

26. FROM (Month, Day, Year)

27. TO (Month, Day, Year)

28. INCOME

A. Net Sales

Minority Interest in Earnings of Subsidiaries

Cost and Expenses

Cost of Goods Sold

Total Costs and Expenses

Depreciation and Amortization

Selling, General, and Admin. Expenses

Earnings Before Taxes

Interest Expense

Taxes on Income

Other Expenses (Itemize)

Income Before Extraordinary Items

Extraordinary Gains (Losses) Net of Taxes

NET INCOME (LOSS)

GSA

FORM

(REV. 3-99)

)SECTION V - BANKING AND FINANCE COMPANY INFORMATION

(Please attach a separate sheet using this format for any additional banks.)

ITEM

BANK 1

BANK 2

29. Name of Bank

30. Contact Person

31. Phone Number

AREA CODE

NUMBER

EXT.

AREA CODE

NUMBER

EXT.

32. Fax Number

AREA CODE

NUMBER

AREA CODE

NUMBER

33. Address

STREET ADDRESS

CITY

STATE

ZIP CODE

CITY

STATE

ZIP CODE

34. Amount Owing ($)

35. Term Loans

Yes

36. Line of Credit

Yes

37. Maximum Amount Authorized ($)

38. Amount Outstanding ($)

39. Loans Secured by Company's Assets - Real and Personal Property

SECURED PARTY NAME

CONTACT NAME

STREET ADDRESS

CITY

STATE

ZIP CODE

SECURING ASSETS

MATURITY DATE

MONTHLY PAYMENT ($)

SECURED PARTY NAME

CONTACT NAME

STREET ADDRESS

CITY

STATE

ZIP CODE

SECURING ASSETS

MATURITY DATE

MONTHLY PAYMENT ($)

SECURED PARTY NAME

CONTACT NAME

STREET ADDRESS

CITY

STATE

ZIP CODE

SECURING ASSETS

MATURITY DATE

MONTHLY PAYMENT ($)

SECURED PARTY NAME

CONTACT NAME

STREET ADDRESS

CITY

STATE

ZIP CODE

SECURING ASSETS

MATURITY DATE

MONTHLY PAYMENT ($)

40.

ARE ANY OF THE ASSETS SHOWN ON THE BALANCE SHEET PLEDGED OR MORTGAGED, EXCEPT AS STATED ABOVE?

41A. IF CONTRACTOR IS A PARTNERSHIP OR THE INDIVIDUAL LIABILITIES OF THE PROPIETOR(S) AND STATE INCOME AND/OR EXCESS PROFIT THE BALANCE SHEET?

SOLE PROPIERTORSHIP, ARE FOR FEDERAL TAXES INCLUDED ON

41B. TOTAL

LIABILITY ($)

NO	YES (Explain in Section VII, Remarks)
YES	NO

42. ARE YOU NOW IN OR PENDING DEFAULT ON ANY OBLIGATIONS, I.E., BANKS, FINANCIAL INSTITUTIONS, SUPPLIERS, OTHER?

NO YES (Provide detailed information in Section VII, Remarks)

GSA

FORM

(REV. 3-99)

)SECTION VI - PRINCIPAL MERCHANDISE OR RAW MATERIAL SUPPLIER INFORMATION

(Please attach separate sheet(s) using this format for additional suppliers.)

43. PAST DUE ACCOUNTS PAYABLE ($)

ITEM

44. SUPPLIER 1

45. SUPPLIER 2

A. Name of Supplier

B. Contact Person

C. Telephone

AREA CODE

NUMBER

EXT.

AREA CODE

NUMBER

EXT.

D. Fax

AREA CODE

NUMBER

AREA CODE

NUMBER

E. Address

STREET ADDRESS

CITY

STATE

ZIP CODE

CITY

STATE

ZIP CODE

F. Amount Now Owing ($)

G. High Credit ($)

ITEM

46. SUPPLIER 3

47. SUPPLIER 4

A. Name of Supplier

B. Contact Person

C. Telephone

AREA CODE

NUMBER

EXT.

AREA CODE

NUMBER

EXT.

D. Fax

AREA CODE

NUMBER

AREA CODE

NUMBER

E. Address

STREET ADDRESS

CITY

STATE

ZIP CODE

CITY

STATE

ZIP CODE

F. Amount Now Owing ($)

G. High Credit ($)

SECTION VII - CONSTRUCTION/SERVICE CONTRACTS INFORMATION (Public Buildings Service Contracts Only)

CONTRACTS IN FORCE

ITEM

48. CONTRACT 1

49. CONTRACT 2

A. Location

B. Owner's Name

C. Address

STREET ADDRESS

CITY

STATE

ZIP CODE

CITY

STATE

ZIP CODE

D. Type of Work

E. Contract Amt. ($)

F. % Completed

G. Est. Comp. Date

ITEM

50. CONTRACT 3

51. CONTRACT 4

A. Location

B. Owner's Name

C. Address

STREET ADDRESS

CITY

STATE

ZIP CODE

CITY

STATE

ZIP CODE

D. Type of Work

E. Contract Amt. ($)

F. % Completed

G. Est. Comp. Date

FORM

(REV. 3-99)

)ITEM

52. CONTRACT 5

53. CONTRACT 6

A. Location

B. Owner's Name

C. Address

STREET ADDRESS

CITY

STATE

ZIP CODE

CITY

STATE

ZIP CODE

D. Type of Work

E. Contract Amt. ($)

F. % Completed

G. Est. Comp. Date

ITEM

54. CONTRACT 7

55. CONTRACT 8

A. Location

B. Owner's Name

C. Address

STREET ADDRESS

CITY

STATE

ZIP CODE

CITY

STATE

ZIP CODE

D. Type of Work

E. Contract Amt. ($)

F. % Completed

G. Est. Comp. Date

LARGEST JOBS YOU HAVE COMPLETED IN THE LAST FIVE YEARS

ITEM

56. JOB 1

57. JOB 2

A. Location

B. Contact's Name

C. Address

STREET ADDRESS

CITY

STATE

ZIP CODE

CITY

STATE

ZIP CODE

D. Telephone

AREA CODE

NUMBER

EXT.

AREA CODE

NUMBER

EXT.

E. Type of Work

F. Contract Amt. ($)

G. Amount Sublet ($)

ITEM

58. JOB 3

59. JOB 4

A. Location

B. Contact's Name

C. Address

STREET ADDRESS

CITY

STATE

ZIP CODE

CITY

STATE

ZIP CODE

D. Telephone

AREA CODE

NUMBER

EXT.

AREA CODE

NUMBER

EXT.

E. Type of Work

F. Contract Amt. ($)

G. Amount Sublet ($)

ITEM

60. JOB 5

61. JOB 6

A. Location

B. Contact's Name

C. Address

STREET ADDRESS

CITY

STATE

ZIP CODE

CITY

STATE

ZIP CODE

D. Telephone

AREA CODE

NUMBER

EXT.

AREA CODE

NUMBER

EXT.

E. Type of Work

F. Contract Amt. ($)

G. Amount Sublet ($)

FORM

(REV. 3-99)

)LIST COMPANIES FROM WHOM YOU OBTAIN SURETY BONDS

ITEM

62. SURETY COMPANY 1

63. SURETY COMPANY 2

A. Company Name

B. Contact's Name

C. Telephone

AREA CODE

NUMBER

EXT.

AREA CODE

NUMBER

EXT.

D. Fax

AREA CODE

NUMBER

AREA CODE

NUMBER

E. Address

STREET ADDRESS

CITY

STATE

ZIP CODE

CITY

STATE

ZIP CODE

64. PRESENT AMOUNT OF BONDING COVERAGE ($)

65. HAS YOUR APPLICATION BOND EVER BEEN DECLINED? please provide detailed information

FOR SURETY

(If Yes, in Remarks)

66. DURING THE PAST FAILURE TO MEET SUPPLIERS? (If Yes,

2 YEARS, HAVE YOU THE CLAIMS OF YOUR please provide detailed

BEEN

SUBCONTRACTORS information

CHARGED WITH A

in Remarks)

YES NO

YES

SECTION VIII - REMARKS

REMARKS (Cite those sections of the form relating to your remarks. If additional space is required, attach additional sheet(s).)

CERTIFICATION

For the purpose of establishing financial responsibility with, or procuring credit from the General Services Administration, we furnish the above as a true and correct statement of our financial condition and further certify that all other statements are true and correct. There has been no material change in the applicant's financial condition since the date of the above statement. We agree to notify you immediately in writing of any materially unfavorable change in our financial condition. In the absence of such notice or of a new and full financial statement, this is to be considered as a continuing statement.

NAME OF BUSINESS	BY (Signature of Authorized Official)
NAME OF AUTHORIZED OFFICIAL (Type or print)	DATE

TITLE OF AUTHORIZED OFFICIAL (Type or print) image1.png

File details come from the government source that posted it. Updated Nov 14, 2017.