Attachment 5 - Reference Information Form.docx

REFERENCE INFORMATION SHEET – N00039-17-R-0056

1. Complete Name of Reference (Government agency, commercial firm, or other organization)

2. Complete Address of Reference

3. Contract Number or other control number

4. Date of contract

5. Date work was begun

6. Date work was completed

7. Contract type, initial contract price, estimated cost and fee, or target cost and profit or fee

8. Final amount invoiced or amount invoiced to date

9a. Reference/Technical point of contact (name, title, address, telephone no. and email address)

9b. Reference/Contracting point of contact (name, title, address, telephone no. and email address)

10. Location of work (country, state or province, county, city)

11. Current status of contract (choose one):

[ ] Work continuing, on schedule [ ] Terminated for Convenience [ ] Work continuing, behind schedule [ ] Terminated for Default [ ] Work completed, no further action pending or underway [ ] Other (explain) [ ] Work completed, routine administrative action pending or underway [ ] Work completed, claims negotiations pending or underway [ ] Work completed, litigation pending or underway

12. Provide brief information describing the success of your firm in furthering the policy of the United States to maximize practicable opportunities for small business concerns, HUB Zone small business concerns, small business concerns owned and controlled by socially and economically disadvantaged individuals, and small business concerns owned and controlled by women to participate in this contract.

13a. Did this contract require a Small Business Subcontracting Plan pursuant to FAR 52.219-9? Yes __, No __.

13b. If “Yes” to 14a, have you regularly submitted SF 294/295 reports on time? Yes ___, No ___.

13c. Attach a copy of your most recently submitted SF 294.

14. Reserved.

15. Indicate if Past Performance information for this contract is located in the Contractor Performance Assessment Reporting System (CPARS), the Past Performance Information Retrieval System (PPIRS) or not in either system.