Attachment19.doc

ATTACHMENT #19: RESPONSIBILITY DETERMINATION SURVEY

IDENTIFICATION

Official Firm Name:____________________________ Telephone:____________

Address:_______________________________________________________________

Number of years in business under present firm name:___________________

Major class of work your firm performs:________________________________

Please check (1), (2) or (3) for type of business:

(1) Corporation ___ (2) Partnership ___ (3) Sole Trader ___

Principal Individuals:

(If a corporation)

(If a partnership)

President:______________________ Name of Partner:_________________

Vice Pres.:_____________________ Name of Partner:_________________

Secretary:______________________ (If Sole Trader)

Treasurer:______________________ Name of Sole Trader:_____________

If a corporation answer the following questions:

(1) Licensed to do business in the State of _____ as of ________ , ____

(2) Date of Incorporation __________ (3) State of _____

EXPERIENCE

Attach a list of the more important contracts completed by your firm in the last two years, including the type of work, approximate cost and name of a person to be used as a reference.

Attach a tabulation of applicable experience of principals in your firm.

Average number of employees during the last twelve months:

Office:_____ Skilled:_____ Unskilled_____

BUSINESS ARRANGEMENTS

In accordance with 52.219-14, Limitations on Subcontracting at least 50 percent of the cost of contract performance incurred for personnel shall be expended for employees of the concern. Explanation: Taking the contract as whole at least 50 percent or more of the whole contract’s resulting cost incurred for personnel must be spent on employees of the prime contractor’s business.

Offerors must provide a brief explanation of how they intend to meet the above requirement (FAR 52.219-14), whether it be that all work will be done by the prime contractor’s business or by a teaming/partnering relationship as outlined in (FAR 9.6).

EQUIPMENT

Attach a list of your major pieces of equipment owned and available when needed for proposed work.

CONTRACTUAL RESPONSIBILITY

Has your firm ever failed to complete any work awarded to it? Y__ N__

If Yes, attach a statement showing where, when, and why.

Has your firm ever failed to complete, within contract time limits, any work awarded to it? Y__ N__

If Yes, attach a statement showing where, when, and why.

Has any officer or partner ever been an officer or partner of some other organization during the past ten (10) years? Y__ N__

If Yes, attach a statement showing where and when.

Has your firm ever asked to be relieved from a bid submitted by it to a public awarding authority during the past ten (10) years? Y__ N__

If Yes, attach a statement showing where and when.

Has your firm ever been charged with or convicted of a violation of any Wage Schedule? Y__ N__

If Yes, attach a statement showing where and when.

CONTRACTOR’S FINANCIAL STATEMENT

Include with this survey the following documents:

· Current Balance Sheet

· Current Statement of Operations

Who prepared those financial statements?_______________________________

Are any of your assets assigned? Y__ N__ If Yes, which are assigned?

For what purpose are they assigned?____________________________________

Person preparing this survey: