S02 - Attachment 5 - Self-Performance Worksheet.docx

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Attached to
J041--HVAC Chiller Maintenance Services Federal contract opportunity
Solicitation number
36C26120Q0714
Issued by
Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 21

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QUOTOR’s SELF PERFORMANCE WORKSHEET

As a Service-Disabled Veteran-Owned Small Business set-aside in accordance with VA Acquisition Regulation (VAAR) 852.219-10, Limitations on Subcontracting – Monitoring and Compliance applies in accordance with VAAR 852.219-74. To demonstrate compliance please complete this worksheet and submit with quote. The Contracting Officer may ask questions about responses on this form. Any such questions will be communications related to responsibility; it will not be considered discussions.

Vendors are required to complete this Worksheet and submit with quote.

a) Quotor’s total proposed price (should be same amount shown in price worksheet for the total): $_______________

b) Total amount to be paid to subcontractors (non-SDVOSBs): $_______________

c) The difference of the amount shown in a) minus the amount shown in b): $_____________

List of intended subcontractors for this project and the value of those subcontracts:

CompanyDUNSAmount
_____________________________________________$_____________
_____________________________________________$_____________

List of “Self-Performed” work activities by the SDVOSB (this should be consistent with the response in the technical evaluation factor):

List of subcontracted work activities:

Include executed copies of your subcontract(s) with this worksheet.

File details come from the government source that posted it. Updated .