COMMONWEALTH OF PENNSYLVANIA
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF TRANSPORTATION
HARRISBURG, PENNSYLVANIA
CONFIDENTIAL
PART 1
CONTRACTOR’S FINANCIAL STATEMENT
NOTE: All requested information must be submitted in the format displayed on this form. The Department
will not accept any substitute submission of the requested information. This form must be completed
in total.
Contractor ( A Corporation
Business Address
Street P.O. Box No. State of Incorporation
( A Co-Partnership
City State Zip Code
( An Individual
Telephone Number ( ) ______________________Fax Number ( )_____________________ ( Affiliate/Subsidiary/
Division
Business Partner Registration Number
Date Submitted
FOR DEPARTMENT USE ONLY:
Financial Statement
Examined/Accepted By:
Accountant Date
REVIEWED FINANCIAL STATEMENT
Section 457.4(b) of the Prequalification Regulations allows for the acceptance of a Reviewed Financial Statement under certain conditions. In order to provide clarification as to how the Department intends to implement this provision of the Prequalification Regulations, the following information is provided:
□ A review statement will be accepted if the net working capital, as determined by the Comptroller’s Office,
□ is less than $50,000.
□ A review statement will not be accepted if the net working capital, as determined by the Comptroller’s Office, is negative.
□ A review statement will not be accepted if the Maximum Capacity Rating (Q) as calculated in Section 457.5(f) exceeds four million dollars ($4,000,000.00).
□ If a Review Statement is not acceptable, you will be informed in writing by the Department that one of the following options is available for consideration:
a) A current audited financial statement may be submitted for the Department’s evaluation.
b) Prequalification as a subcontractor may be requested as noted in Section 457.4(a)(5). Submission of Part 1, Financial Statement, is not required for subcontractor approval.
□ An Accountant’s Certificate to accommodate a Review Statement has been inserted for your use, if necessary, following this sheet.
ACCOUNTANTS CERTIFICATE
I (We) have reviewed the accompany balance sheet and related financial statement of _____________________ _________________________for the period ended ______________________________, in accordance with standards established by the American Institute of Certified Public Accountants. All information included in these financial statements is the representation of the management of the company.
A review consists principally of inquiries of company personnel and analytical procedures applied to financial data. It is substantially less in scope than an examination in accordance with generally accepted auditing standards, the objective of which is the expression of an opinion regarding the financial statements taken as a whole. Accordingly, we do not express such an opinion.
Based on our review, we are not aware of any material modifications that should be made to the accompanying financial statements in order for them to be in conformity with generally accepted accounting principles.
Registration Number ____________________________ Signed ______________________________________
Name of Certified Public Accountant/Public Accountant
________________________________________________________________________________________________________________________________
Accounting Firm Name
Authorized to do business in __________________________________________________________________
State
__________________________________________________________________________________________________________
Address
ACCOUNTANTS CERTIFICATE
_______________________
Date
I (We) have audited the balance sheet and related financial statements of _______________________________ for the period ended ________________________________. These statements are the responsibility of the company’s management. Our responsibility is to express an opinion on these statements based on our audits.
We conducted our audits in accordance with generally accepted auditing standards. Those standards require that we plan and perform the audit to obtain reasonable assurance whether the financial statements are free of material misstatement. Our audit included examining, on a test basis, evidence supporting the amounts and disclosures in the financial statements. Our audit also included assessing the accounting principles used and significant estimates made by management, as well as evaluating the overall financial statement presentation. Any lines of credit extended by banks were also verified. We believe that our audits provide a reasonable basis for our opinion.
In our opinion, the financial statements referred to above present fairly, in all material respects, the financial position of_______________________________________________ as of ___________________________, in conformity with generally accepted accounting principles.
Registration Number ________________ Signed__________________________________________________
Name of Certified Public Accountant/Public Accountant
________________________________________________________________________________________________
Accounting Firm Name
Authorized to do business in __________________________________________________________________
State
________________________________________________________________________________________________________________________________
Address
BALANCE SHEET [see pg. 7]
as of ( A Corporation
Submitted by _____________________ ( A Co-Partnership
Date ( An Individual
|ASSETS |ADJUSTED |
| |WORKING |
| |CAPITAL |
| |[see pg.7-(b)] |
|A. CASH _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ $_______________ | |
| 1. On Hand _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ $_______________ |$_______________ |
| 2. In Banks (Unrestricted) _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _______________ | _______________ |
| 3. Elsewhere (Unrestricted) _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _______________ | _______________ |
| 4. Other _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _______________ | |
|B. BID DEPOSITS, GUARANTIES_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _$_______________ | _______________ |
|C. ACCOUNTS RECEIVABLE (Less Related Reserves) _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ $_______________ | |
| 1. Completed Contracts (Exclude Claims not yet Approved) _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ $_______________ | _______________ |
| 2. Uncompleted Contracts (Monthly Estimates Exclusive of Retainage) _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _______________ | _______________ |
| 3. Affiliated Companies (Due within one year) _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _______________ | _______________ |
| 4. Other_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _______________ | |
|NOTES AND ACCEPTANCES RECEIVABLE _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ $______________ | |
|1. Trade (Portion due within one year) _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ $_______________ |_______________ |
| 2. Affiliated Companies (Due within one year) _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _______________ | _______________ |
| 3. Other _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _______________ | |
|INVESTMENTS _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ $______________ | |
|1. Listed Stocks and Bonds [see pg.7-(c )] _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ $_______________ |_______________ |
| 2. Unlisted Stocks and Bonds (Exclude stock in Affiliated Companies) [see pg.7-(d)] _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _______________ | _______________ |
| 3. Joint Ventures [see pg.7-(e)] _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _______________ | _______________ |
| 4. Other _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _______________ | |
|F. INVENTORIES _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ $_______________ | |
| 1. Materials, Supplies, Stock Available for Contracts or Sale _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __$_______________ | _______________ |
| 2. Other _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _______________ | |
|G. ACCRUED INCOME _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ $_ ______________ | |
| 1. Work in Progress – Unbilled (Include Retainage) _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ $_______________ | _______________ |
| 2. Other _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _______________ | |
|H. PREPAID EXPENSES _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ $________________ | _______________ |
|I. PLANT PROPERTY (Less Reserve for Depreciation) _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ $ ________________ | |
| 1. Machinery and Equipment (Used in Operation of Business) _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ $_______________ | |
| 2. Land and Buildings (Used in Operation of Business) _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _______________ | |
| 3. Furniture and Fixtures _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _______________ | |
|J. OTHER ASSETS _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ $ _________________ | |
| 1. Land and Buildings – Not Used in Operation of Business _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _______________ | |
| 2. Other _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _______________ | |
|TOTAL ASSETS _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ $_________________ | $_______________ |
BALANCE SHEET (continued)
|LIABILITIES AND NET WORTH | |
| |ADJUSTED |
| |WORKING |
|LIABILITIES: |CAPITAL |
|NOTES PAYABLE _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _$_______________ | |
|Banks, Trade, Sundry (Due within one year) _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ $_______________ |$_______________ |
|Affiliated Companies (Due within one year) _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _______________ |_______________ |
|Other _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _______________ | |
|ACCOUNTS PAYABLE _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _$_______________ | |
|Payable to Subcontractors _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ $_______________ |$_______________ |
|Trade _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ $_______________ |_______________ |
|Affiliated Companies _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ $_______________ |_______________ |
|Other _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ $_______________ | |
|ACCRUED TAXES _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ $_______________ | |
|Income _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ $_______________ |$_______________ |
|Other _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _$_______________ |_______________ |
|ACCRUED SALARIES, WAGES AND OTHER EXPENSES _ _ _ _ _ _ _ _ _ _ _$_______________ |$_______________ |
|O. MORTGAGES AND BONDS PAYABLE _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _$_______________ | |
|Due within one year _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ $_______________ |$_______________ |
|Other _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ $_______________ | |
|OTHER LIABILITIES _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _$______________ | |
| | |
|TOTAL LIABILITIES _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ $_______________ |$_______________ |
| | |
|NET WORTH: | |
|INDIVIDUAL OR PARTNERSHIP CAPITAL _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ $________________ | |
|R. CAPITAL STOCK: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ $_______________ | |
|Common _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ $_______________ | |
|Preferred _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ $_______________ | |
|SURPLUS _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ $_______________ | |
|Appropriated _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ $_______________ | |
|Unappropriated _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ $_______________ | |
|Paid-In _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ $_______________ | |
|TOTAL CAPITAL AND SURPLUS _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _$_______________ | |
|Less: Treasury Stock _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _$_______________ | |
| | |
|TOTAL NET WORTH _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ $_______________ | |
| | |
|TOTAL LIABILITIES AND NET WORTH _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ $_______________ | |
BALANCE SHEET OF ________________________________________________________________ as of ______________________________________
CONTINGENT LIABILITIES:
Liability on notes receivable discounted or sold $_______________________
Liability on accounts receivable pledged, assigned or sold ________________________
Liability as bondsman ________________________
Liability as guarantor on contracts or on accounts of others ________________________
Liability under any judgements, suits or claims pending against you or any member of your firm ________________________
Other contingent liabilities (itemize) ________________________
Total $_______________________
Instructions For Balance Sheet:
a) The Balance Sheet shall reflect financial condition in accordance with generally accepted accounting principles.
b) The contractor shall enter applicable amounts on all the lines provided. The Pennsylvania Department of Transportation shall review items excluded from the Adjusted Working Capital column and determine the propriety of any further inclusions. The Department reserves the right of final determination of all items and may make verification thereof to the extent deemed necessary.
c) Use market value rather than cost for listed stocks and bonds.
d) Use of the lower of cost or market for unlisted stocks and bonds.
e) That share of Adjusted Working Capital of the joint venture, which is attributable to the contractor being evaluated. Furnish supporting data.
f) If more space is required for data on supporting schedules, attach additional sheets.
DETAILS RELATIVE TO ASSETS
SCHEDULE A – CASH
|BALANCE SHEET ITEM |NAME AND LOCATION OF BANK OR OTHER DEPOSITORY |DEPOSITED IN NAME OF |AMOUNT |
| | | |$ |
| | | | |
| | | | |
| | | | |
| | | | |
| | | | |
| | | | |
| | | | |
| | | | |
| | | | |
| | | | |
| | | | |
| | | | |
| | | | |
| | | | |
|TOTAL |$ |
|Indicate how much is restricted as to use for purposes other than current operations. Describe – | |
| |$ |
SCHEDULE B – BID DEPOSITS, GUARANTIES
|BALANCE SHEET ITEM |DEPOSITED WITH: NAME AND ADDRESS |PURPOSE OF DEPOSIT |DATE DEPOSITED |DATE RECOVERABLE |AMOUNT |
| | | | | |$ |
| | | | | | |
| | | | | | |
| | | | | | |
| | | | | | |
| | | | | | |
| | | | | | |
| | | | | | |
| | | | | | |
| | | | | | |
| | | | | | |
|TOTAL |$ |
2
SCHEDULE C – ACCOUNTS RECEIVABLE
PART 1 Accounts Receivable from completed contracts exclusive of claims not yet approved for payments:
|BALANCE SHEET ITEMS |DESIGNATION OF CONTRACT NAME AND ADDRESS OF OWNER |AMOUNT OF CONTRACT |AMOUNT RECEIVABLE |WHEN DUE |
| | |$ |$ | |
| | | | | |
| | | | | |
| | | | | |
| | | | | |
| | | | | |
| | | | | |
| | | | | |
| | | | | |
|TOTAL |$ | |
|Have any of the above been assigned, sold or pledged? ______________________________________ If so, state amount , to whom, and reason _________________ |
SCHEDULE C – ACCOUNTS RECEIVABLE
Accounts Receivable from uncompleted contracts:
Amount Due on monthly estimates exclusive of retainage (Col. 4) $ ________________
PART 2 Note: Transfer Total from Col. 5 to Schedule G – Accrued Income
|BALANCE SHEET |DESIGNATION OF CONTRACT AND NAME AND |AMOUNT OF CONTRACT |TOTAL AMOUNT EARNED AS OF BALANCE|CASH PREVIOUSLY RECEIVED |Amounts Due on Outstanding|Unbilled Balance of Total|
|ITEM |ADDRESS OF OWNER | |SHEET DATE | |Monthly Estimates |Earned Including |
| | | | | |Exclusive of Retainage |Retainage Due* |
| | | |(2) | |(4) | |
| | |(1) | |(3) | |(5) |
| | |$ |$ |$ |$ |$ |
| | | | | | | |
| | | | | | | |
| | | | | | | |
| | | | | | | |
| | | | | | | |
| | | | | | | |
| | | | | | | |
| | | | | | | |
| | | | | | | |
| | | | | | | |
|TOTAL |$ |$ |$ |$ |
|Have any of the above been assigned, sold or pledged? _____________________ If so, state amount, to whom, and reason ____________________________________ |
*”Retainage Due” includes Securities held in lieu of retainage
SCHEDULE C – ACCOUNTS RECEIVABLE (cont’d)
PART 3 Accounts receivable from other than construction contracts:
|BALANCE SHEET ITEM |RECEIVABLE FROM: NAME AND ADDRESS |DESCRIPTION |WHEN DUE |AMOUNT |
| | | | |$ |
| | | | | |
| | | | | |
| | | | | |
| | | | | |
| | | | | |
| | | | | |
| | | | | |
|TOTAL | |$ |
|Have any of the above been assigned, sold or pledged? ______________________________________ If so, state amount , to whom, and reason _________________ |
SCHEDULE D – NOTES AND ACCEPTANCES RECEIVABLE
|BALANCE SHEET ITEM |RECEIVABLE FROM: NAME AND ADDRESS |DATE OF MATURITY |HOW SECURED |FACE VAULE |
| | | | |$ |
| | | | | |
| | | | | |
| | | | | |
| | | | | |
| | | | | |
| | | | | |
|TOTAL |$ |
Indicate your contingent liability for discounted notes and acceptances receivable:
|WITH WHOM DISCOUNTED – ADDRESS |MAKER OF NOTE |DATE OF MATURITY |FACE VALUE |
| | | |$ |
| | | | |
| | | | |
| | | | |
| | | | |
|TOTAL |$ |
SCHEDULE E – INVESTMENT
PART 1 STOCKS AND BONDS (Do Not Include Securities Deposited With State Treasurer in Lieu of Retainage)
*Indicate by asterisk stocks and bonds which are unlisted
|BALANCE SHEET ITEM|DESCRIPTION |NAME AND ADDRESS OF ISSUING COMPANY |QUANTITY |PRESENT MARKET |COST |AMOUNT PLEDGED OR IN |
| | | | |VALUE |(BOOK VALUE) |ESCROW |
| | | | |$ |$ |$ |
| | | | | | | |
| | | | | | | |
| | | | | | | |
| | | | | | | |
| | | | | | | |
| | | | | | | |
| | | | | | | |
| | | | | | | |
| | | | | | | |
| | | | | | | |
| | | | | | | |
| | | | | | | |
| | | | | | | |
| | | | | | | |
| | | | | | | |
| | | | | | | |
| | | | | | | |
|TOTAL | |$ |$ |$ |
If pledged or in Escrow, state for whom and reason:
| |
| |
| |
| |
| |
SCHEDULE E – INVESTMENTS
PART 2 – JOINT VENTURES FURNISH BALANCE SHEET OR STATEMENT OF WORKING CAPITAL FOR JOINT VENTURES
|BALANCE SHEET ITEM |NAME AND DESCRIPTION OF ENTERPRISE |CONTRACTORS NET INVESTMENT |AMOUNT OF CONTRACTOR’S RATIO OF JOINT VENTURE WORKING |
| | | |CAPITAL |
| | |$ |$ |
| | | | |
| | | | |
|TOTAL |$ |
SCHEDULE F - *INVENTORIES: -MATERIALS, OPERATING-MAINTENANCE
SUPPLIES AND PARTS TO BE CONSUMED
IN COMPLETION OF CONTRACTS, OR FOR SALE
|BALANCE SHEET ITEM |DESCRIPTION OF MATERIAL |QUANTITY |BOOK VAULE |
| | | |$ |
| | | | |
| | | | |
| | | | |
| | | | |
| | | | |
| | | | |
| | | | |
| | | | |
| | | | |
| | | | |
| | | | |
| | | | |
| | | | |
| | | | |
| | | | |
| | | | |
| | | | |
| | | | |
| | | | |
| | | | |
| | | | |
| | | | |
| | | | |
| | | | |
| | | | |
| | | | |
| | | | |
| | | | |
| | | | |
| | | | |
| | | | |
| | | | |
| | | | |
| | | | |
|TOTAL |$ |
SCHEDULE G – ACCRUED INCOME
|BALANCE SHEET ITEM |DESCRIPTION |DATE OF EXPECTED RECEIPT OR CREDIT|AMOUNT |
| | | |$ |
| | | | |
| | | | |
| | | | |
| | | | |
| | | | |
| | | | |
| | | | |
| | | | |
| | | | |
| | | | |
| | | | |
| | | | |
| | | | |
| | | | |
| | | | |
|TOTAL | | |$ |
SCHEDULE H – PREPAID EXPENSES
|BALANCE SHEET ITEM |DESCRIPTION |WHEN DUE |AMOUNT |
| | | |$ |
| | | | |
| | | | |
| | | | |
| | | | |
| | | | |
| | | | |
| | | | |
| | | | |
| | | | |
| | | | |
| | | | |
| | | | |
| | | | |
|TOTAL | | |$ |
SCHEDULE I- PLANT PROPERTY
PART 1 – MACHINERY AND EQUIPMENT (BOOK VALUE) USED IN OPERATION OF BUSINESS
|BALANCE SHEET ITEM|QUANTITY |DESCRIPTION AND CAPACITY OF ITEMS |AGE OF ITEMS |PURCHASE PRICE |DEPRECIATION |BOOK VAULE |
| | | | | |CHARGED OFF | |
| | | | | | | |
| | | | | | | |
| | | | | | | |
| | | | | | | |
| | | | | | | |
| | | | | | | |
| | | | | | | |
| | | | | | | |
| | | | | | | |
| | | | | | | |
| | | | | | | |
| | | | | | | |
| | | | | | | |
| | | | | | | |
| | | | | | | |
| | | | | | | |
| | | | | | | |
| | | | | | | |
| | | | | | | |
| | | | | | | |
| | | | | | | |
| | | | | | | |
| | | | | | | |
| | | | | | | |
| | | | | | | |
| | | | | | | |
| | | | | | | |
| | | | | | | |
| | | | | | | |
| | | | | | | |
| | | | | | | |
|TOTAL | | |$ |
Total amount of equipment pledged as security for loans $____________
SCHEDULE I – PLANT PROPERTY
PART 2 – LAND AND BUILDINGS (BOOK VALUE) USED IN OPERATION OF BUSINESS
|BALANCE SHEET ITEM |DESCRIPTION AND LOCATION OF |TITLE HELD IN WHOSE NAME |TOTAL COST INCLUDING |ASSESSED VALUE |BOOK VALUE AFTER DEPRECIATION |
| |PROPERTY | |IMPROVEMENTS | |CHARGED OFF |
| | | |$ |$ |$ |
| | | | | | |
| | | | | | |
| | | | | | |
| | | | | | |
| | | | | | |
| | | | | | |
| | | | | | |
| | | | | | |
| | | | | | |
| | | | | | |
| | | | | | |
| | | | | | |
| | | | | | |
|TOTAL | | | | |$ |
SCHEDULE I – PLANT PROPERTY
PART 3 – FURNITURE AND FIXTURES (BOOK VALUE)
|BALANCE SHEET ITEM |DESCRIPTION |AMOUNT (BOOK VALUE) |
| | |$ |
| | | |
| | | |
| | | |
| | | |
| | | |
| | | |
| | | |
| | | |
| | | |
| | | |
|TOTAL | |$ |
SCHEDULE J – OTHER ASSETS
PART 1 – LAND AND BUILDINGS OWNED BUT NOT USED IN OPERATION OF BUSINESS (BOOK VALUE)
|BALANCE SHEET ITEM |DESCRIPTION AND LOCATION OF PROPERTY |TITLE HELD IN WHOSE NAME |COST |DEPRECIATION RESERVE |BOOK VALUE |
| | | |$ |$ |$ |
| | | | | | |
| | | | | | |
| | | | | | |
| | | | | | |
|TOTAL | | | | |$ |
SUPPLEMENTARY DATA:
For Individual or Co-Partnership Personally Owned Real Estate Not Connected with the Business
|DESCRIPTION OF PROPERTY |LOCATION OF PROPERTY |TITLE HELD IN WHOSE NAME |ENCUMBRANCE AGAINST |ASSESSED VALUE |
| | | |PROPERTY | |
| | | |$ |$ |
| | | | | |
| | | | | |
| | | | | |
| | | | | |
| | | | | |
SCHEDULE J – OTHER ASSETS
PART 2 – OTHER
|BALANCE SHEET ITEM |DESCRIPTION: (Describe Fully) |AMOUNT |
| | |$ |
| | | |
| | | |
| | | |
| | | |
| | | |
|TOTAL | |$ |
DETAILS RELATIVE TO LIABILITIES AND NET WORTH
SCHEDULE K – NOTES PAYABLE
|BALANCE SHEET ITEM |PAYEE: NAME AND ADDRESS |MATURITY DATE |HOW SECURED |CURRENT PORTION |LONG TERM PORTION|
| | | | |(K-1) (K-2) |(K-3) |
| | | | |$ |$ |
| | | | | | |
| | | | | | |
| | | | | | |
| | | | | | |
| | | | | | |
| | | | | | |
| | | | | | |
| | | | | | |
| | | | | | |
| | | | | | |
| | | | | | |
|TOTAL | | | |$ |$ |
SCHEDULE L – ACCOUNTS PAYABLE
PART 1 – PAYABLE TO SUBCONTRACTORS
|BALANCE SHEET |DESIGNATION OF CONTRACT AND NAME OF |TOTAL AMOUNT OF WORK LET TO SUBCONTRACTOR |VALUE OF WORK DONE BASED ON LAST ESTIMATE |AMOUNT PAID TO |AMOUNT DUE SUBCONTRACTOR |
|ITEM |SUBCONTRACTOR | |APPROVED |DATE |INCLUDING RETAINAGE |
| | |$ |$ |$ |$ |
| | | | | | |
| | | | | | |
| | | | | | |
| | | | | | |
| | | | | | |
| | | | | | |
| | | | | | |
| | | | | | |
| | | | | | |
| | | | | | |
| | | | | | |
| | | | | | |
|TOTAL | | | | |$ |
SCHEDULE L – ACCOUNTS PAYABLE
PART 2 – TRADE – AFFILIATED COMPANIES – OTHER
|BALANCE SHEET ITEM |CREDITOR: NAME AND ADDRESS |DESCRIPTION |DATE PAYABLE |AMOUNT |
| | | | |$ |
| | | | | |
| | | | | |
| | | | | |
| | | | | |
| | | | | |
| | | | | |
| | | | | |
| | | | | |
| | | | | |
| | | | | |
| | | | | |
| | | | | |
| | | | | |
| | | | | |
| | | | | |
| | | | | |
| | | | | |
| | | | | |
| | | | | |
|TOTAL | | | |$ |
SCHEDULE M – ACCRUED TAXES
|BALANCE SHEET ITEM |NATURE OF TAX |FOR WHAT PERIOD |PAYABLE TO |DATE PAYABLE |AMOUNT |
| | | | | |$ |
| | | | | | |
| | | | | | |
| | | | | | |
| | | | | | |
| | | | | | |
| | | | | | |
|TOTAL | | | | |$ |
SCHEDULE N – ACCRUED SALARIES, WAGES, INTEREST AND OTHER EXPENSES
|BALANCE SHEET ITEM |DESCRIPTION |PERIOD COVERED |DATE PAYABLE |AMOUNT |
| | | | |$ |
| | | | | |
| | | | | |
| | | | | |
| | | | | |
| | | | | |
| | | | | |
| | | | | |
| | | | | |
| | | | | |
| | | | | |
| | | | | |
| | | | | |
| | | | | |
|TOTAL | | | |$ |
SCHEDULE O– MORTGAGES AND BONDS PAYABLE
PART 1 -MORTGAGES PAYABLE
|BALANCE SHEET ITEM |DESCRIPTION |HOLDER OF LIEN |MATURITY DATE |HOW SECURED |AMOUNT |
| |(Term – Interest Rate) |NAME – ADDRESS | | | |
| | | | | |$ |
| | | | | | |
| | | | | | |
| | | | | | |
| | | | | | |
| | | | | | |
| | | | | | |
| | | | | | |
| | | | | | |
| | | | | | |
| | | | | | |
| | | | | | |
| | | | | | |
|TOTAL | | | | |$ |
SCHEDULE O– MORTGAGES AND BONDS PAYABLE
PART 2 BONDS PAYABLE
|BALANCE SHEET ITEM |DESCRIPTION (Bondholder – Interest Rate) |HOW SECURED |DATE DUE |FACE VALUE |
| | | | |$ |
| | | | | |
| | | | | |
| | | | | |
| | | | | |
| | | | | |
| | | | | |
| | | | | |
| | | | | |
|TOTAL | | | |$ |
SCHEDULE P – OTHER LIABILITIES
|BALANCE SHEET ITEM |DESCRIPTION |AMOUNT |
| | |$ |
| | | |
| | | |
| | | |
| | | |
| | | |
| | | |
|TOTAL | |$ |
SCHEDULE Q – INDIVIDUAL OR PARTNERSHIP CAPITAL
|BALANCE SHEET ITEM |NAME AND ADDRESS |CAPITAL |NET INCREASE |CAPITAL BALANCE SHEET |
| | |BEGINNING OF PERIOD |(DECREASE) |DATE |
| | |$ |$ |$ |
| | | | | |
| | | | | |
| | | | | |
| | | | | |
| | | | | |
|TOTAL | |$ |$ |$ |
SCHEDULE R – CAPITAL STOCK
|BALANCE SHEET |KIND OF STOCK |PAR VALUE |AUTHORIZED |OUTSTANDING |TREASURY STOCK |
|ITEM | |OR |(NO. SHARES) | | |
| | |*STATED VALUE | | | |
| | | | |ISSUED |AMOUNT |NO. SHARES |COST PER SHARE |AMOUNT |
| | | | |(NO. SHARES) | | | | |
| | | | | |$ | | |$ |
| | | | | | | | | |
| | | | | | | | | |
| | | | | | | | | |
| | | | | | | | | |
| |TOTALS | | | |$ | | |$ |
| | | | | | | | | |
| |PREFERRED: | | | | | | | |
| | | | | |$ | | | |
| | | | | | | | | |
| | | | | | | | | |
| | | | | | | | | |
| | | | | | | | | |
|TOTALS | | |$ | |$ |
*Show Amount per share if issued at premium or discount
SCHEDULE S – SURPLUS
|BALANCE SHEET ITEM| | |
| |APPROPRIATED SURPLUS: |AMOUNT |
| | |$ |
| | | |
| | | |
| | | |
| |TOTAL APPROPRIATED SURPLUS |$ |
| | | |
| |TOTAL UNAPPROPRIATED SURPLUS |$ |
| |PAID-IN SURPLUS: | |
| | |$ |
| | | |
| | | |
| | | |
| | | |
| |TOTAL PAID-IN SURPLUS |$ |
LINE-OF-CREDIT STATEMENTS
Line-of-Credit Statements may be submitted from your banks for the purpose of establishing your financial qualifications in determining your classification and rating. Such statements must, however, be specific as to amount.
The next page, properly executed, is the official form, which must be used for a bank line-of-credit statement. Any alterations will make the form null and void.
If more than one bank line-of-credit statement is being submitted the second or subsequent statements must be on the Pennsylvania Department of Transportation official form.
The name of the contractor being pre-qualified is the only name that is to be shown on the form.
Name of Bank_______________________________
Address____________________________________
Date_______________________________________
Department of Transportation
Prequalification Office
400 North Street – 7th Floor West
Harrisburg, Pennsylvania 17120-0094
A line of credit in the maximum amount of $________________________________has been placed at the disposal of _________________
_____________________________for use when, as, and if needed throughout the one-year period beginning _________________________________, subject to the usual conditions, including the requirement that the borrower’s financial condition and other circumstances remain satisfactory to the bank at the time of any proposed borrowing. Should there be any reduction, termination, or increase in this line of credit, the Department of Transportation would appreciate being notified of these changes as soon as possible. The banking facility will not be held accountable in any fashion by the Department.
The following items, listed as liquid assets in Part 1 of the questionnaire being submitted by ________________________________________________ have been pledged to secure the line of credit mentioned above:
*The line of credit mentioned has been given with full knowledge of accommodations extended by other banks in amounts as follows:
**It is not intended that this statement confer to the Department of Transportation or the Commonwealth of Pennsylvania any rights in and to
said line of credit nor shall this statement create any obligation of _________________________________________________ except as
expressly set forth herein (Name of Bank)
AFFIDAVIT
State of ________________________________________
County of ______________________________________ SS:
_______________________________________________________________________ being duly sworn, deposes and says that he is ______________________ of the _______________________________________________________________________________, the bank named in and which executed the foregoing statement.
Sworn to before me this ________________________________ day of ____________________________, (Year)
________________________________________________________ __________________________________________________
(Notary Public) (Bank Officer Sign Here)
(NOTARIAL SEAL)
FOR A CORPORATION
COMPLETE THE FOLLOWING:
Corporate Name_________________________________________________________________________________________________________________
Authorized Capital ______________________________________________________________________________________________________________
Paid-in Capital __________________________________________________________________________________________________________________
When Incorporated __________________________________________________________ In What State ______________________________________
Name and Address of Officers:
President _______________________________________________________________________________________________________________________
Vice-President __________________________________________________________________________________________________________________
Secretary _______________________________________________________________________________________________________________________
Treasurer _______________________________________________________________________________________________________________________
AFFIDAVIT FOR CORPORATION
STATE OF _____________________________________
COUNTY OF ___________________________________ SS:
The undersigned hereby declares: that the foregoing is a true statement of the financial condition of the corporation herein first named, as of the date herein first given; that this statement is in response to a questionnaire and that any depository, vendor or other agency herein named is hereby authorized to supply such party with any information necessary to verify this statement.
_______________________________________________________________________________________________being duly sworn, deposes and says that he is _________________________________________________ of the _____________________________________________________________the
(Title)
corporation described in and which executed the foregoing statement; that he is familiar with the books of the said corporation showing its financial condition; that the foregoing financial statement, taken from the books of the said corporation, is a true and accurate statement of the financial condition as of the date thereof and that the answers to the foregoing interrogatories are true.
Sworn to before me this
____________________________________day of _________________________________, (Year) ____________________________________
(Signature of Officer)
______________________________________________
Notary Public
(NOTARIAL SEAL)
FOR A CO-PARTNERSHIP
COMPLETE THE FOLLOWING:
Firm Name __________________________________________________________________________________________________
Date of Organization __________________________________________________________________________________________
State whether Co-partnership is general or limited ___________________________________________________________________
If limited, explain fully ________________________________________________________________________________________
Name and Address of Partners:
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
AFFIDAVIT FOR CO-PARTNERSHIP
STATE OF ______________________________
COUNTY OF ____________________________ SS:
The undersigned hereby declares: that the foregoing is a true statement of the financial condition of the co-partnership herein first named, as of the date herein first given; that this statement is in response to a questionnaire and that any depository, vendor or other agency herein named is hereby authorized to supply such party with any information necessary to verify this statement.
______________________________________________________________________________ being duly sworn, deposes and says that he is a member of the firm of _______________________________________________; that he is familiar with the books of the said firm showing its financial condition; that the foregoing financial statement, taken from the books of the said firm, is a true and accurate statement of the financial condition of the said firm as of the date thereof and that the answers to the foregoing interrogatories are true.
Sworn to before me this
______________________day of ________________, (Year) Signatures ____________________________________
(ALL PARTNERS OF FIRM MUST SIGN)
________________________________________________________________ ___________________________________________
(NOTARY PUBLIC) ____________________________________
____________________________________
(NOTARIAL SEAL) ____________________________________
FOR AN INDIVIDUAL
COMPLETE THE FOLLOWING:
Firm Name __________________________________________________________________________________________________
AFFIDAVIT FOR INDIVIDUAL
STATE OF __________________________
COUNTY OF ________________________ SS:
The undersigned hereby declares: that the foregoing is a true statement of the financial condition of the individual herein first named, as of the date herein first given; that this statement is in response to a questionnaire and that any depository, vendor or other agency herein named is hereby authorized to supply such party with any information necessary to verify this statement.
________________________________________________________________________being duly sworn, deposes and says that the foregoing financial statement, taken from his books, is a true and accurate statement of his financial condition as of the date thereof and that the answers to the foregoing interrogatories are true.
Sworn to before me this
___________________________day of _________, (Year) ____________________________________
(SIGNATURE OF INDIVIDUAL)
______________________________________________________
(NOTARY PUBLIC)
(NOTARIAL SEAL)
PENNSYLVANIA DEPARTMENT OF TRANSPORTATION
BUREAU OF CONSTRUCTION & MATERIALS
400 NORTH STREET – 7TH FLOOR WEST
HARRISBURG, PENNSYLVANIA 17120
CONFIDENTIAL – PART 2
ORGANIZATION AND EXPERIENCE STATEMENT
NOTE: All requested information must be submitted in the format displayed on this form. The Department will not accept any substitute submission of the requested information. This form must be completed in total.
Name of Company _________________________________________________________________
Address__________________________________________________________________________
____________________________________________________________________________________________
_____________________________________________________________________________________________
Telephone & Fax Numbers _____________________________________________________________________
Federal Identification No. ______________________________________________________________________
Business Partner Registration No. _________________________________________(REQUIRED)
OUT-OF-STATE CONTRACTOR - Pennsylvania Resident Agent
Name __________________________________________________________________________
Address __________________________________________________________________________
_________________________________________________________________________________
______________________________________________________________________________
NOTE: The Department reserves the right to request additional information for prequalification at any time as per the requirements of Title 67 Transportation, Section 457.17, Notification.
NOTARY PAGE
Date at ________________________________________ this __________________________
day of ________________________________________________, _______ (year)
___________________________________________
NAME OF ORGANIZATION
___________________________________________ SIGNATURE AND TITLE OF PERSON SIGNING
COUNTY OF ________________________________________
SS:
COMMONWEALTH / STATE OF _______________________
_______________________________________ being duly sworn, deposes and says that he/she
(PRINT NAME)
is __________________________________ of __________________________________
(TITLE) (NAME OF ORGANIZATION)
and that the answers to the foregoing questions and all statements therein contained are true and correct.
Sworn to before me this
_________ day of ___________, _______ (year)
Notary Public
My commission Expires
(NOTARIAL SEAL)
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF TRANSPORTATION
HARRISBURG, PENNSYLVANIA 17120
CONFIDENTIAL
PART 3
CONTRACTOR’S AFFIRMATIVE ACTION STATEMENT
NOTE: All requested information must be submitted in the format displayed on this form. The Department will not accept any substitute submission of the requested information. This form must be completed in total.
Contractor ______________________________________________________
Equal Employment Policy Officer ___________________________________
Date Submitted __________________________________________________
Business Partner Registration No. ______________________________________
For Department use only:
Accepted by: _______________________________
Signature/Title Date
NOTARY PAGE
Dated at _________________________________________ this____________________
day of __________________________________________, ___________________ (year)
_______________________________________ NAME OF ORGANIZATION
_______________________________________
SIGNATURE AND TITLE OF PERSON SIGNING
COUNTY OF ______________________________________________
COMMONWEALTH / STATE OF _______________________________
__________________________________ being duly sworn, deposes and says that he/she (PRINT NAME)
is __________________________________ of __________________________________
(TITLE) (NAME OF ORGANIZATION)
and that the answers to the foregoing questions and all statements therein contained are true and correct.
Sworn to before me this
________ day of _______________, _______ (year)
_____________
Notary Public
My commission Expires
(NOTARIAL SEAL)
-----------------------
Corporate
Seal
................
................
In order to avoid copyright disputes, this page is only a partial summary.
To fulfill the demand for quickly locating and searching documents.
It is intelligent file search solution for home and business.
Related searches
- commonwealth of pennsylvania department of state
- commonwealth of pennsylvania bureau of state employment
- commonwealth of pennsylvania department of ed
- commonwealth of pennsylvania employment
- commonwealth of pennsylvania state jobs
- commonwealth of pennsylvania dept of state
- commonwealth of pennsylvania address
- commonwealth of pennsylvania department state
- commonwealth of pennsylvania docket search
- commonwealth of pennsylvania job openings
- commonwealth of pennsylvania phone number
- commonwealth of pennsylvania physical form