GSA 527.doc

DOC document 319 KB Posted Apr 29, 2011

Attached to: Security Guard Services
Solicitation number: JFK11R00017
Issued by: John F. Kennedy Center for the Performing Arts

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Financial Disclosure

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CONTRACTOR'S QUALIFICATIONS AND FINANCIAL INFORMATION

OMB NO.

Expires:

3090-0007

10/31/2001

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

B. CONTRACTOR

F. 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 VII, REMARKS

YES

A. NAME

A. HAVE YOU, OR ANY OF YOUR AFFLIIATES 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?

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)

Yes

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

YES NO

IF "YES", COMPLETE THE ITEMS BELOW

AGENCY

CLAIM AMOUNT

PAYMENT

MATURITY

BALANCE

15A. AGENCY INVOLVED WITH IN DELINQUENCY

15B. AMOUNT OF DELIQUENCY ($)

16. ARE YOU CURRENTLY RECEIVING GOVERNMENT FINANCING?

YES

NO (Go to Section III)

17. COMPLETE THE ITEMS BELOW IF APPLICABLE

TYPE OF FINANCING

AUTHORIZED ($)

IN USE ($)

GOVERNMENT AGENCY INVOLVED

A. INDUSTRIAL REVEHUE BONDS

B. GUARANTEED LOANS

C. ADVANCED PAYMENTS

D. PROGRESS PAYMENTS

E. OTHER (Specify)

GENERAL SERVICES ADMINISTRATION

GSA Form 527 (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 or accountant of accounting firm.

18. ARE YOU THE INCUMBENT CONTRACTOR FOR THIS?

YES NO

19A. NAME

20. IF TRANSCRIBED STATEMENTS DIFFER FROM INDEPENDENT ACCOUNTANT'S, PLEASE DESCRIBE ADJUSTMENT IN SECTION VII, 19B. STREET ADDRESS

REMARKS. ALL OF THE LISTED FIGURES ARE

ACTUAL

US DOLLARS

19C. CITY

19D. STATE

19E. 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 STATEMENTS

ATTACHED

24. ASSETS

25. LIABILITIES AND NET WORTH

A. Current Assets

A. Current Liabilities

Cash

Accounts payable

Short term cash investment

Notes payable (current)

Accounts receivable, less allowance

Current portion of long term debt for doubtful accounts of $

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

Other long term debt

Amortization

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

Good will, 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

Earnings Before Taxes

Selling, General, and Admin. Expenses

Taxes on Income

Other Expenses (Itemized)

Income Before Extraordinary Items

Extraordinary Gains (Losses) Net of Taxes

NET INCOME (LOSS)

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

SECTION IV – 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

EXT.

AREA CODE

NUMBER

EXT.

33. Address

STREET ADDRESS

CITY

STATE

ZIP CODE

CITY`

STATE

ZIP CODE

34. Amount

Owing (S)

35. Term Loans

Yes

36. Line of Credit

Yes

37. Maximum

Amount

Authorized (S)

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 PLEADGED OR MORTGAGED, EXCEPT AS STATED ABOVE?

No Yes (Explain in Section VII, Remarks) 41A. IF A CONTRACTOR IS A PARTNERSHIP OR SOLE PAROPRIETORSHIP, ARE THE INDIVIDUAL LIABILITIES OF THE PROPRIETOR(S) FOR FEDERAL AND STATE INCOME AND/OR EXCESS PROFIT TAXES INCLUDED ON THE BALANCE SHEET?

Yes No

41B. TOTAL LIABILITY ($)

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 527 (REV. 3-99) PAGE3

SECTION V – PRINCIPAL MERCHANDISE OR RAW MATERIAL SUPPLIER INFORMATION

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

4. 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 Number

AREA CODE

NUMBER

EXT.

AREA CODE

NUMBER

EXT.

E. Address

STREET ADDRESS

CITY

STATE

ZIP CODE

CITY`

STATE

ZIP CODE

34. Amount Now

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 Number

AREA CODE

NUMBER

EXT.

AREA CODE

NUMBER

EXT.

E. Address

STREET ADDRESS

CITY

STATE

ZIP CODE

CITY`

STATE

ZIP CODE

34. Amount Now

G. High Credit ($)

SECTION VI – 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

GSA Form 527 (REV. 3-99) PAGE4

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. Amt. 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. Amt. 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. Amt. Sublet ($)

GSA Form 527 (REV. 3-99) PAGE5

LIST COMPANIES FROM WHOM YOU OBTAIN SURETY BONDS

ITEM

62. SURETY COMPANY 1

63. SURETY COMPANY 2

A. Company Name

B. Contact Name

C. Telephone

AREA CODE

NUMBER

EXT.

AREA CODE

NUMBER

EXT.

D. Fax Number

AREA CODE

NUMBER

EXT.

AREA CODE

NUMBER

EXT.

E. Address

STREET ADDRESS

CITY

STATE

ZIP CODE

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).

YES NO

65 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

SECTION VII – 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)

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

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