GSA Form 527.pdf

CONTRACTOR'S QUALIFICATIONS AND FINANCIAL INFORMATION OMB No.: 3090-0007 Expires: 1/31/2005

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

1B. STREET ADDRESS

1C. CITY 1D. STATE 1E. ZIP CODE

2. TYPE OF ORGANIZATION (Check one)

A. SOLE PROPRIETORSHIP

B. GENERAL PARTNERSHIP

C. LIMITED PARTNERSHIP

D. CORPORATION

E. SUBCHAPTER S CORPORATION

I. OTHER (Specify below)

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

9. KIND OF BUSINESS

A. MANUFACTURER

B. CONTRACTOR

C. WHOLESALER

D. RETAILER

F. OTHER (Specify) B. FIFO

A. LIFO C. AVERAGE COST

D. OTHER (Specify)

11. OWNERSHIP INFORMATION-PARTNERS-PRINCIPAL STOCKHOLDERS-OTHERS

NAME

TITLE

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

ACTUAL TITLE G OR L

% BUSINESS

OWNED

12. PARENT COMPANY (If applicable)

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

INFORMATION IN SECTION VIII, REMARKS

YES NO

A. NAME

B. CITY C. STATE

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

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

C. DO YOU HAVE ANY CONTINGENT LIABILITIES?

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

SECTION II - GOVERNMENT FINANCIAL AID AND INDEBTEDNESS

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

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

14B. DO YOU OWE THE

GOVERNMENT

FOR ANY CON-

TRACT OR OTHER

CLAIMS?

YES NO

IF "YES", COMPLETE THE ITEMS BELOW

AGENCY CLAIM AMOUNT PAYMENT MATURITY BALANCE

15A. AGENCY INVOLVED WITH DELINQUENCY 15B. AMOUNT OF DELINQUENCY ($)

16. ARE YOU CURR-

RENTLY RECEIVING

GOVERNMENT

FINANCING?

YES NO

YES

NO (Go to Section III)

17. COMPLETE ITEMS BELOW IF APPLICABLE

A. INDUSTRIAL REVENUE BONDS

B. GUARANTEED LOANS

C. ADVANCED PAYMENTS

D. PROGRESS PAYMENTS

TYPE OF FINANCING AUTHORIZED ($) IN USE ($) GOVERNMENT AGENCY INVOLVED

E. OTHER (Specify)

GENERAL SERVICES ADMINISTRATION GSA FORM 527 (REV. 3-99)

F. LIMITED LIABILITY COMPANY

G. JOINT VENTURE

H. TRUST

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

NO

19A. NAME

19B. STREET ADDRESS

19C. CITY 19D. STATE 19E. ZIP CODE

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

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

LISTED FIGURES ARE:

ACTUAL

IN THOUSANDS

IN MILLIONS

U.S. DOLLARS

FOREIGN CURRENCY (Specify)

21. BALANCE SHEET AS OF (Month, Day, Year) 22. FISCAL YEAR ENDS (Month, Day, Year) 23. PREPARED STMTS.

YES

ARE ATTACHED

24. ASSETS 25. LIABILITIES AND NET WORTH

A. Current Assets A. Current Liabilities

Cash Short Term cash investments Accounts receivable, less allowance for doubtful accounts of $ Inventories Other current assets (Itemize below)

Total Current Assets

B. Property, Plant and Equipment

Accounts payable Notes payable (current) Current portion of long term debt Accrued expenses Accrued taxes on income/excess profits Other current liabilities (Itemize)

Total Current Liabilities

B. Other Liabilities

Land Buildings and equipment Leasehold improvements Less accumulated depreciation and amortization Total Property, Plant and Equipment

C. Other Assets Investments in and advance to affiliated company

Goodwill, less amortization Due from officer, employee Other (Itemize)

Total Other Assets

D. TOTAL ASSETS

Mortgages Bonds Deferred income taxes Other long term debt

Total Other Liabilities

Total Liabilities

C. Minority Interest in Subsidiary D. Net Worth

Preferred stock Common stock Additional paid-in capital Retained earnings/owner's equity Less, Treasury stock

Total Net Worth

E. TOTAL LIABILITIES AND NET WORTH

SECTION IV - INCOME STATEMENT

26. FROM (Month, Day, Year) 27. TO (Month, Day, Year)

A. Net Sales

28. INCOME

Cost and Expenses Cost of Goods Sold Depreciation and Amortization

Selling, General, and Admin. Expenses Interest Expense Other Expenses (Itemize)

Minority Interest in Earnings of Subsidiaries

Total Costs and Expenses

Earnings Before Taxes Taxes on Income Income Before Extraordinary Items Extraordinary Gains (Losses) Net of Taxes

NET INCOME (LOSS)

GSA FORM 527 (REV.3-99 ) PAGE 2

SECTION V - BANKING AND FINANCE COMPANY INFORMATION

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

ITEM

29.Name of Bank

30.Contact Person

31.Phone Number

32.Fax Number

33.Address

34.Amount Owing ($)

35.Term Loans

36.Line of Credit

37. Maximum Amount Authorized ($)

38.Amount Outstanding ($)

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

BANK 1 BANK 2

AREA CODE NUMBER

AREA CODE NUMBER EXT.

AREA CODE NUMBER

STREET ADDRESS

CITY STATE ZIP CODE

Yes No

Yes No

Yes No

Yes No

A.

B.

C.

D.

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?

41B. TOTAL

LIABILITY ($)

41A. IF CONTRACTOR IS A PARTNERSHIP OR SOLE PROPIERTORSHIP, ARE

THE INDIVIDUAL LIABILITIES OF THE PROPIETOR(S) FOR FEDERAL

AND STATE INCOME AND/OR EXCESS PROFIT TAXES INCLUDED ON

THE BALANCE SHEET?

YES NO

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

NO YES (Explain in Section VII, Remarks)

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

GSA FORM 527 (REV. 3-99) PAGE 3

AREA CODE NUMBER EXT.

STREET ADDRESS

CITY STATE ZIP CODE

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

AREA CODE NUMBER EXT.

AREA CODE NUMBER

STREET ADDRESS

CITY STATE ZIP CODE

ITEM 46. SUPPLIER 3 47. SUPPLIER 4

A. Name of Supplier B. Contact Person

C. Telephone

D. Fax

E. Address

F. Amount Now Owing ($)

G. High Credit ($)

A. Name of Supplier B. Contact Person

C. Telephone

D. Fax

E. Address

F. Amount Now Owing ($)

G. High Credit ($)

AREA CODE NUMBER EXT.

AREA CODE NUMBER

STREET ADDRESS

CITY STATE ZIP CODE

AREA CODE NUMBER EXT.

AREA CODE NUMBER

AREA CODE NUMBER EXT.

AREA CODE NUMBER

STREET ADDRESS

CITY STATE ZIP CODE

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

CONTRACTS IN FORCE

STREET ADDRESS

CITY STATE ZIP CODE

GSA FORM 527 (REV. 3-99) PAGE 4

ITEM 48. CONTRACT 1 49. CONTRACT 2

A. Location B. Owner's Name

C. Address

D. Type of Work E. Contract Amt. ($) F. % Completed G. Est. Comp. Date

STREET ADDRESS

CITY STATE ZIP CODE

STREET ADDRESS

CITY STATE ZIP CODE

ITEM

A. Location B. Owner's Name

C. Address

D. Type of Work E. Contract Amt. ($) F. % Completed G. Est. Comp. Date

50. CONTRACT 3 51. CONTRACT 4

STREET ADDRESS

CITY STATE ZIP CODE

STREET ADDRESS

CITY STATE ZIP CODE

ITEM 52. CONTRACT 5 53. CONTRACT 6

A. Location B. Owner's Name

C. Address

D. Type of Work E. Contract Amt. ($) F. % Completed G. Est. Comp. Date

STREET ADDRESS

CITY STATE ZIP CODE

STREET ADDRESS

CITY STATE ZIP CODE

ITEM

A. Location B. Owner's Name

C. Address

D. Type of Work E. Contract Amt. ($) F. % Completed G. Est. Comp. Date

54. CONTRACT 7 55. CONTRACT 8

STREET ADDRESS

CITY STATE ZIP CODE

STREET ADDRESS

CITY STATE ZIP CODE

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

D. Telephone

E. Type of Work F. Contract Amt. ($) G. Amount Sublet ($)

STREET ADDRESS

CITY STATE ZIP CODE

AREA CODE NUMBER EXT.

STREET ADDRESS

CITY STATE ZIP CODE

AREA CODE NUMBER EXT.

ITEM 58. JOB 3 59. JOB 4

A. Location B. Contact's Name

C. Address

D. Telephone

E. Type of Work F. Contract Amt. ($) G. Amount Sublet ($)

STREET ADDRESS

CITY STATE ZIP CODE

AREA CODE NUMBER EXT.

STREET ADDRESS

CITY STATE ZIP CODE

AREA CODE NUMBER EXT.

ITEM 60. JOB 5 61. JOB 6

A. Location B. Contact's Name

C. Address

D. Telephone

E. Type of Work F. Contract Amt. ($) G. Amount Sublet ($)

STREET ADDRESS

CITY STATE ZIP CODE

AREA CODE NUMBER EXT.

STREET ADDRESS

CITY STATE ZIP CODE

AREA CODE NUMBER EXT.

GSA FORM 527 (REV. 3-99) PAGE 5

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

D. Fax

E. Address

AREA CODE NUMBER EXT.

AREA CODE NUMBER

STREET ADDRESS

CITY STATE ZIP CODE

AREA CODE NUMBER EXT.

AREA CODE NUMBER

STREET ADDRESS

CITY STATE ZIP CODE

64. PRESENT AMOUNT OF BONDING

COVERAGE ($)

65. HAS YOUR APPLICATION FOR SURETY

BOND EVER BEEN DECLINED (If Yes, please provide detailed information in Remarks)

66. DURING THE PAST 2 YEARS, HAVE YOU BEEN CHARGED WITH A

FAILURE TO MEET THE CLAIMS OF YOUR SUBCONTRACTORS OR

SUPPLIERS (If Yes, please provide detailed information in Remarks)

YES NO YES NO

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)

TITLE OF AUTHORIZED OFFICIAL (Type or print)

DATE

GSA FORM 527 (REV. 3-99) PAGE 6