B.08. Attachment 9 - Determination of Responsibility Form.pdf
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- Attached to
- Amendment 002 to W912EP-22-R-0024 Cano Martin Pena Waterway Vegetation Removal San Juan, Puerto Rico
- Solicitation number
- W912EP-22-R-0024
About this file
This document contains a Determination of Responsibility Form and details of a related federal contract opportunity. The Determination of Responsibility Form requests financial, performance, and integrity information from prospective contractors to assist the Contracting Officer in determining responsibility. The federal contract opportunity is a solicitation from the U.S. Army Corps of Engineers Jacksonville District seeking vegetation removal and disposal services on approximately 40 acres of the Cano Martin Pena Waterway in San Juan, Puerto Rico. The requirement is set aside for HUBZone small businesses and involves terrestrial and aquatic vegetation removal, debris clean-up and shredding, transport, and disposal at a final facility. The Corps anticipates awarding one non-personal services contract for these services.
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ATTACHMENT 7 – DETERMINATION OF RESPONSIBILITY FORM
Prospective Contractor: __________________________________________
Solicitation No: W912EP22R0024
Project Title: Cano Martin Pena Waterway Vegetation Removal, San Juan, Puerto Rico
The following information is provided to assist the Contracting Officer in determining whether or not the proposed contractor meets the general standards of responsibility enumerated at FAR
9.104-1 and DFARS 209.104-1.FAR 9.104-1 General Standards. To be determined responsible, a prospective contractor must:
(a) HAVE ADEQUATE FINANCIAL RESOURCES TO PERFORM THE CONTRACT, OR THE ABILITY TO OBTAIN THEM (SEE 9.104-3(b))
The prospective contractor's financial statement for the period ending __________________ shows assets to liabilities at a ratio of ______ to ______.
PROVIDE A COPY OF YOUR LATEST FINANCIAL STATEMENT.
Banking References
(Provide signed reference on letterhead from financial institution supporting each banking reference.)
1st bank's name: __________________________________________
Telephone #: _____________________________________________
Address: ________________________________________________
Person: _________________________________________________
Title: ___________________________________________________
Length of time with bank: ___________________________________
Credit Rating: ____________________________________________
Number/type of accounts: __________________________________
Amount in each account (# of figures): ________________________
Credit line:______________________ Secured/Unsecured
Outstanding loans:_______________________ Secured/Unsecured
Banking References (continued)
2nd bank's name:__________________________________________
Telephone #: _____________________________________________
Address: ________________________________________________
Person: _________________________________________________
Title: ___________________________________________________
Length of time with bank: ___________________________________
Credit Rating: ____________________________________________
Number/type of accounts: ___________________________________
Amount in each account (# of figures): _________________________
Credit line:______________________ Secured/Unsecured
Outstanding loans:_______________________ Secured/Unsecured
(b) BE ABLE TO COMPLY WITH THE REQUIRED OR PROPOSED DELIVERY OR
PERFORMANCE SCHEDULE, TAKING INTO CONSIDERATION ALL EXISTING
COMMERCIAL AND GOVERNMENTAL BUSINESS COMMITMENTS
(c) HAVE A SATISFACTORY PERFORMANCE RECORD (SEE 9.104-3(c) and Subpart
42.15)
Performance References
1st company: _____________________________________________
Telephone #: _____________________________________________
Address: _________________________________________________
Name: ___________________________________________________
Title: ____________________________________________________
Location and type of work: ___________________________________
Completed on time? ________________________________________
On budget? _______________________________________________
Quality of work? ____________________________________________
Management cooperative? ____________________________________
Any problems encountered: ___________________________________
Performance References (continued)
2nd company: ______________________________________________
Telephone #: _______________________________________________
Address: ___________________________________________________
Name: _____________________________________________________
Title: ______________________________________________________
Location and type of work: _____________________________________
Completed on time? __________________________________________
On budget? _________________________________________________
Quality of work? ______________________________________________
Management cooperative? ______________________________________
Any problems encountered: _____________________________________
(d) HAVE A SATISFACTORY RECORD OF INTEGRITY AND BUSINESS ETHICS
Trade References
1st company: ________________________________________________
Telephone #: ________________________________________________
Address: ____________________________________________________
Name: _____________________________________________________
Title: _______________________________________________________
Length of time with company: ____________________________________
Credit line: ___________________________________________________
Average monthly business: ______________________________________
High credit: ___________________________________________________
Payment history: _______________________________________________
Takes discounts: _______________________________________________
Trade References (continued)
2nd company: _________________________________________________
Telephone #: __________________________________________________
Address: _____________________________________________________
Name: _______________________________________________________
Title: _________________________________________________________
Length of time with company: ______________________________________
Credit line: _____________________________________________________
Average monthly business: ________________________________________
High credit: _____________________________________________________
Payment history: _________________________________________________
Takes discounts: _________________________________________________
(e) HAVE THE NECESSARY ORGANIZATION, EXPERIENCE, ACCOUNTING AND
OPERATIONAL CONTROLS, AND TECHNICAL SKILLS, OR THE ABILITY TO
OBTAIN THEM (INCLUDING, AS APPROPRIATE, SUCH ELEMENTS AS
PRODUCTION CONTROL PROCEDURES, PROPERTY CONTROL SYSTEMS,
QUALITY ASSURANCE MEASURES, AND SAFETY PROGRAMS APPLICABLE TO
MATERIALS TO BE PRODUCED OR SERVICES TO BE PERFORMED BY THE
PROSPECTIVE CONTRACTOR AND SUBCONTRACTORS) (SEE 9.104-3(b))
Workman's Compensation Experience Modification Rate (EMR):
2019: ___ 2020: ___ 2021: ___
If EMR is greater than 1, an explanation as to why the EMR exceeds the currently established satisfactory threshold of 1.0 must be provided.
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