COMMONWEALTH OF PENNSYLVANIA
PENNSYLVANIA DEPARTMENT OF TRANSPORTATION
BUREAU OF CONTRUCTION & MATERIALS
400 NORTH STREET – 7th FLOOR WEST
HARRISBURG, PENNSYLVANIA 17120-0094
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 $_______________________
Instructions For Balance Sheet:
a) The Balance Sheet shall reflect financial condition in accordance with generally accepted accounting principles.
b) The contractor shall enter applicable amounts on all the lines provided. The Pennsylvania Department of Transportation shall review items excluded from the Adjusted Working Capital column and determine the propriety of any further inclusions. The Department reserves the right of final determination of all items and may make verification thereof to the extent deemed necessary.
c) Use market value rather than cost for listed stocks and bonds.
d) Use of the lower of cost or market for unlisted stocks and bonds.
e) That share of Adjusted Working Capital of the joint venture, which is attributable to the contractor being evaluated. Furnish supporting data.
f) If more space is required for data on supporting schedules, attach additional sheets.
DETAILS RELATIVE TO ASSETS
SCHEDULE A – CASH
|BALANCE SHEET ITEM |NAME AND LOCATION OF BANK OR OTHER DEPOSITORY |DEPOSITED IN NAME OF |AMOUNT |
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|TOTAL |$ |
|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 |
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|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 |
| | |$ |$ | |
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|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) |
| | |$ |$ |$ |$ |$ |
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|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 |
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|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 |
| | | | |$ |
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|TOTAL |$ |
Indicate your contingent liability for discounted notes and acceptances receivable:
|WITH WHOM DISCOUNTED – ADDRESS |MAKER OF NOTE |DATE OF MATURITY |FACE VALUE |
| | | |$ |
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|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 |
| | | | |$ |$ |$ |
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|TOTAL | |$ |$ |$ |
If pledged or in Escrow, state for whom and reason:
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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 |
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|TOTAL |$ |
SCHEDULE F - *INVENTORIES: -MATERIALS, OPERATING-MAINTENANCE
SUPPLIES AND PARTS TO BE CONSUMED
|BALANCE SHEET ITEM |DESCRIPTION OF MATERIAL |QUANTITY |BOOK VAULE |
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|TOTAL |$ |
SCHEDULE G – ACCRUED INCOME
|BALANCE SHEET ITEM |DESCRIPTION |DATE OF EXPECTED RECEIPT OR CREDIT|AMOUNT |
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|TOTAL | | |$ |
SCHEDULE H – PREPAID EXPENSES
|BALANCE SHEET ITEM |DESCRIPTION |WHEN DUE |AMOUNT |
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|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 | |
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|TOTAL | | |$ |
Total amount of equipment pledged as security for loans $____________
SCHEDULE I – PLANT PROPERTY
PART 2 – LAND AND BUILDINGS (BOOK VALUE) USED IN OPERATION OF BUSINESS
|BALANCE SHEET ITEM |DESCRIPTION AND LOCATION OF |TITLE HELD IN WHOSE NAME |TOTAL COST INCLUDING |ASSESSED VALUE |BOOK VALUE AFTER DEPRECIATION |
| |PROPERTY | |IMPROVEMENTS | |CHARGED OFF |
| | | |$ |$ |$ |
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| | | | | | |
| | | | | | |
| | | | | | |
| | | | | | |
| | | | | | |
| | | | | | |
| | | | | | |
| | | | | | |
| | | | | | |
|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.
Form completed by (print): ________________________________________
Title: ________________________________________
APPLICATION
The undersigned hereby applies for qualification to perform the following types of work, as described in the Pennsylvania Department of Transportation Specifications, Publication 408M (408).
|WORK CLASSIFICATION (CHECK THOSE DESIRED) |
|WORK |CODE |CLASSIFICATION |X |
|EARTHWORK |A |Clearing & Grubbing | |
| |B |Building Demolition | |
| |C |Roadway Excavating & Grading | |
| |C1 |Non-Roadway, Drainage, Structure Related Excavation & Grading | |
| |C2 |Drilling & Blasting | |
| |C5 |Anchors | |
| |C6 |Drilling | |
|BASE COURSE |C4 |Rubblizing | |
| |D |Rigid Base Course | |
| |E |Flexible Base Course | |
|PAVEMENT |F |Bituminous Pavement | |
| |F1 |Bituminous Pavement Patching & Repair | |
| |F2 |Bituminous Joint &Crack Sealing | |
| |F3 |Milling, Rumble Strips, Scarification (Bituminous or Concrete) | |
| |F4 |Bituminous SurfaceTreatments, Seal Coats | |
| |G |Rigid Pavement | |
| |G1 |Rigid Pavement Patching & Repair | |
| |G2 |Diamond, Carbide Grinding (Concrete or Bituminous) | |
| |G3 |Spall Repair | |
| |G4 |Joint Rehabilitation, Sawing & Sealing (Concrete or Bituminous) | |
| |W |Railroad Construction | |
|INCIDENTAL |B1 |Asbestos Removal | |
|CONSTRUCTION | | | |
| |C3 |Geotextiles | |
| |H |Drainage, Water Main, Storm Sewer | |
| |H1 |Pipe & Culvert Cleaning | |
| |H2 |Pavement Base Drains | |
| |J |Guide Rail, Steel Median Barrier, Fences | |
| |J1 |Concrete Median Barrier | |
| |J2 |Fencing, Railings | |
| |K |Curbs, Sidewalks, Inlets, Manholes, Etc. | |
| |K1 |Masonry Work | |
| |K2 |Concrete & Masonry Coatings | |
| |L |Slabjacking-Subsealing | |
|ROADSIDE |M |Landscaping | |
| |M1 |Selective Tree Removal, Trimming | |
| |M2 |Silt Barrier Fence, Gabions, Erosion Control | |
| |M3 |Seeding & Soil Supplements | |
| |N |Building Construction & Related Trades | |
| |N1 |Related Building Trades | |
|TRAFFIC |O |Pavement Markings | |
|ACCOMMODATIONS | | | |
|& CONTROL | | | |
| | | | |
| |O1 |Raised, Recessed Pavement Markers | |
| |O2 |Plastic Applications | |
| |O3 |Paint Applications | |
| |P |Highway/Sign Lighting, Traffic Signal Control | |
| |P1 |Camera Monitoring Systems(CCTV) | |
| |P2 |Highway Advisory Radio System (HAR) | |
| |P3 |Dynamic Message Signs (DMS) | |
| |P4 |Integrated Communications Systems | |
| |P5 |Level 1 (Hardware) System Integrator | |
| |P6 |Level 2 (Software) System Integrator | |
| |P7 |Level 3 (Hardware & Software) Integrator | |
| |P8 |Highway/Sign Lighting, Electrical | |
| |Q |Maintenance & Protection of Traffic | |
| |R |Sign Placement (Post/Structure Mounted) | |
| |R1 |Sign Structures | |
| |S |Cement Concrete Bridges Over 120’ (37M) | |
|STRUCTURES |S1 |Single Span Bridges to 120’ (37M) | |
|(Bridges) | | | |
| |S2 |Repair & Rehabilitation of Damaged Structures | |
| |S3 |Modified Concrete Deck Overlays | |
| |S4 |Bridge Culverts, Pedestrian Bridges, Timber Bridges | |
| |S5 |Structural Walls | |
| |S6 |Prestressed Beam Installation | |
| |S7 |Rebar Installation | |
| |S8 |Transportation Tunnels | |
| |S9 |Bridge Deck Placement or Repairs | |
| |S0 |Marine Work | |
| |T |Steel Bridges | |
| |T1 |Bridge Removal | |
| |T3 |Steel Bridges Over 120’ (37M) | |
| |T4 |Welding | |
| |T5 |Bearing Pads & Seals | |
| |T6 |Expansion Dams | |
| |T7 |Bridge Drainage | |
| |T8 |Shear Studs, Metal Bridge Deck Forms | |
| |T9 |Parapets | |
| |U |Pile Driving | |
| |U1 |Caissons | |
| |V |Steel Painting (High Performance) | |
| |V1 |Steel Painting (Conventional) | |
| |V2 |Steel Surface Preparation | |
| | | | |
List the states in which you are prequalified for highway construction work and applicable maximum capacity rating:
STATE AMOUNT OF MAXIMUM CAPACITY RATING
____________________________________________ __________________________________________________
____________________________________________ __________________________________________________
____________________________________________ __________________________________________________
1. How many years has your organization been in business as a contractor under your present business name?
______________________________________________________________________________________________
2. How many years experience in highway construction work has your organization had? ________________________
3. List the construction experience of the officers and management personnel including superintendents of your organization.
|INDIVIDUAL’S NAME |PRESENT POSITION |YEARS OF CONSTRUCTION EXPERIENCE |TYPE OF CONSTRUCTIONWORK |IN WHAT |
| |OR TITLE | | |POSITION |
| | | | | |
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4. Has your company ever failed to complete any work awarded to you? _____________________________________
If so, give dates, projects and reasons therefore________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
5. Has any officer or partner of your organization ever been an officer or partner of some other organization that failed to complete a construction contract?
______________________________________________________________________________________________
If so, state name of individual, other organization, dates, project, and reason therefore _________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
6. Has any officer or partner of your organization ever failed to complete a construction contract handled in his own name?
______________________________________________________________________________________________
If so, state name of individual, name of owner and reason therefore _______________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
7. Has your organization or an officer of your organization ever been denied prequalification in this state or any other state under this name or any other name? ________________________________________________________________
If so, please indicate state(s), and explain reasons for denial______________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
8. Has your organization or an officer of your organization ever been disqualified or removed from a bidding list in this
State or any other state, or from a Federal Government bidding list under this name or any other name? __________
_____________________________________________________________________________________________
If so, please indicate state(s) and/or Federal agency and explain reasons for denial. __________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
9. List all affiliated or subsidiary organizations and companies. ___________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
Please complete information on Part 2, Page 5 if you are requesting prequalification approval for subsidiary
organizations and/or companies.
10. List all organizations and individuals that have a financial interest of ten percent (10%) or more in your company.
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
11. List all persons having a financial interest in this organization and who also have a financial interest in another
organization prequalified or eligible to bid in this state or any other state. ________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
12. List any other organization or individual who controls or influences the bidding of this organization. __________
___________________________________________________________________________________________
___________________________________________________________________________________________
REQUEST FOR SUBSIDIARY PREQUALIFICATION
1) Name
Address
Telephone Number ( )
Fax Number ( )
Federal Identification No. ______
List of Officers, Management Personnel, and Superintendents:
Individual Name Position or Title
(Make additional copies if needed)
13. List contracts which will show the various types of work completed by your organization in the past 5 years and/or presently under construction.
|NAME AND ADDRESS OF OWNER* |NAME AND LOCATION OF PROJECT – DETAIL |NAME AND ADDRESS OF PRIME |CONTRACT |Was contract completed |Were there any |Were there any liens, claims, |
| |DESCRIPTION OF WORK PERFORMED |CONTRACTOR |AMOUNT |on time? |penalties imposed? |or stop notices filed against |
|*Address must be adequate to assure|(Include e.g. quantities, lengths, | | | | |job? |
|reply to inquiry and verification.|miles, sizes, types, etc.) |If you were a subcontractor | | |If “YES” give amount | |
|Failure to receive reply will delay| | | |If “NO” explain why |and explain under |If “YES” explain under Number |
|processing of application. | | |(If subcontractor, indicate |under Number 15. |Number 15. |15. |
| | | |subcontracted amount) | | | |
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(Make additional copies if needed)
14. PLANT AND EQUIPMENT
List equipment owned. Also list and indicate separately, equipment under lease or otherwise available to you, with attached explanation of the arrangements.
The list of equipment should be identical with those shown in your Financial Statement, and must be shown below to be credited with the technical evaluation of your application.
|QUANTITY |ITEM |SIZE OR |CONDITION |YEARS OF |
| | |CAPACITY | |SERVICE |
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15. Explanation of details in connection with non-completion of contracts; penalties imposed; liens, claims and
stop notices filed against contracts listed under No. 13. ________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
16. Complete statement of misdemeanor convictions involving moral turpitude, convictions of bidding related
crimes, and all felony convictions of the contractor, as well as the contractor’s directors, principal officers
and key employees.______________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
17. Give any further or relevant, pertinent and material facts that will justify approval of the requested work
classifications.__________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
18. If you are a parent organization and desire to do business in Pennsylvania through branch offices, indicate
below the official name and address of each branch. Also indicate a mailing address if different than the
address listed on the Cover Sheet, Page 1.
NAME ADDRESS
_____________________________ __________________________________________________
_____________________________ __________________________________________________
_____________________________ __________________________________________________
_____________________________ __________________________________________________
_____________________________ __________________________________________________
19.
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)
PENNSYLVANIA DEPARTMENT OF TRANSPORTATION
BUREAU OF CONSTRUCTION & MATERIALS
400 NORTH STREET – 7TH FLOOR WEST
HARRISBURG, PENNSYLVANIA 17120
CONFIDENTAL
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
Pursuant to the provisions of Executive Order 1996-8; Nondiscrimination Clauses; Pennsylvania Human Relations Act; Pennsylvania Department of Transportation, Chapter 457 Regulations (Prequalification); Civil Rights Act of 1964, as amended; Executive Order 11246, as amended; 23, USC, Sec 22 of Federal-aid Highway Act of 1968; and other related laws:
1. It is the policy of the ________________________________ Co. to ensure that applicants are employed and that employees are treated, during employment, without regard to their race, religion, sex, age, color, national origin and/or disability. Such action shall include: employment upgrading, demotion, or transfer, recruitment or recruitment advertising; layoff or termination; rates of pay or other forms of compensation; and selection for training, including apprenticeship, pre-apprenticeship; and/or on-the-job training.
2. __________________________________ is the name of Contractor’s Equal Employment Policy Officer.
3. It is hereby agreed, as part of this prequalification, that the following steps be taken to ensure equal opportunity in employment:
a. Require that all advertisements for personnel contain the notation “An Equal Opportunity Employer M/F”* and that all advertisements be inserted in newspapers having a large general circulation in the area and among minority groups.
b. Utilize, direct and systematically recruit personnel through all public and private employee referral sources likely to yield qualified minority groups and female applicants, including but not limited to schools, colleges, minority groups, and female organizations. Establish and maintain a current list of minority and female recruitment sources, provide written notification to these recruitment sources and community organizations when the contractor or its unions have employment opportunities available; follow-up and maintain documentation of the organizations’ responses.
c. Encourage minority and female applicants through referral by current employees.
4. It is further hereby agreed, as part of this prequalification, that in order to ensure nondiscriminatory hiring, the following steps have been taken:
a. All members of company staff authorized to hire and discharge or to recommend such action are fully cognizant of the company’s Equal Employment Opportunity Policy and the Policy of the Department.
b. All work supervisors, personnel officers, company officers and other employees have been advised of our above-stated Equal Employment Opportunity Policy.
c. All labor unions and other recruitment sources will post in conspicuous places, available to employees, agents, applicants for employment, and other persons, a notice to be provided by the contracting agency setting forth the provisions of the Nondiscrimination Clause.
*M/F means Minority/Female
d. Cooperation will be aggressively sought with unions, where applicable, to develop programs to ensure qualified minorities and females equal opportunity for employment and training.
e. It is further agreed to diligently attempt in conjunction with the labor unions, where applicable, to obtain qualified minority and female representation in all classifications on the job and in all phases of the work.
f. The unions which represent our work force are: (If you are non-union, please indicate)
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
and it has been their policy to accept for membership, qualified personnel without regard to race, religion, color, sex, age or ethnic origin.
5. As part of this prequalification, we will make use of apprenticeship and/or other training programs in one or more of the following ways:
a. Continually assisting minorities and females to enter pre-apprenticeship and apprenticeship training programs,
b. Actively aiding minority and female employees to increase skills to be eligible for upgrading,
c. Regularly participating in programs for equitable consideration of all applicants, for union apprenticeship, such programs having been approved by the Bureau of Apprenticeship and Training of the United States Department of Labor, and/or the Pennsylvania Apprenticeship and Training Council, where applicable.
d. We presently have apprenticeship or on-the-job training programs for the following skills and/or crafts: (If none, please state.)
_______________________________________________________
_______________________________________________________
_______________________________________________________
6. Where the practices of a union, any training program or other source of recruitment will result in the exclusion of minorities and females, so that the contractor will be unable to meet its obligation under the Contract Compliance Regulations issued by the Governor’s Office of Administration, the United States Department of Labor, or this nondiscrimination clause, the contractor shall then employ and fill vacancies through other nondiscriminatory employment procedures.
7. Are you currently a recipient of contracts with the Commonwealth of PA in addition to PennDOT? If yes, please indicate agency(ies).
__________ YES __________ NO
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
8. Has any federal or state agency conducted an EEO compliance review of your firm within the past two years? If yes, please indicate agency(ies) and date(s).
__________ YES __________ NO
_____________________________________________________________
___________________________________________________________
9. 9. Does the contractor have a written Affirmative Action Plan?
10.
__________ YES __________ NO
10. It is also agreed that:
a. When bids are being solicited, the contractor shall actively solicit bids from minority-disadvantaged and/or female subcontractors.
b. Officials will conduct systematic reviews in order to ensure that the company’s EEO program is implemented.
c. We shall physically include the provisions of this nondiscrimination clause and all other applicable EEO Clauses in every subcontract, [i.e., Commonwealth Nondiscrimination Clause, Management Directive 215.16 (6-99), Specific Equal Employment Opportunity Responsibilities, (23 USC); Notice of Requirement For Affirmative Action To Ensure Equal Employment Opportunity, (Executive Order 11246, as Amended); Required Contract Provisions Federal-Aid Construction Contracts, (FAR-CA, Sept. 1975); Item 1999-9999, Trainees and/or Equal Employment Opportunity (100% State)], so that such provisions will be binding upon each subcontractor.
d. We will submit any required training program (if applicable), in accordance with established Department procedures and Items 1999-9999 or 1999-0000 Trainees/Special Training Provisions. Required training program will be submitted 10 days following the Notice to Proceed.
1) Submit an Initial Report (EO-364) for each trainee prior to filling any training position(s).
2) Submit monthly Training Reports (EO-365) in a timely manner.
11. We will furnish all information and reports required by Federal and State Rules and Regulations, as well as permit access to contractor’s employees, books, records and accounts by the Pennsylvania Department of Transportation and the Governor’s Office of Administration, for purposes of investigation to ascertain compliance.
12. We agree to notify all subcontractors, unions, vendors or suppliers of their responsibilities to comply with state and/or federal regulations.
13. We agree to send to each subcontractor, union, supplier of employees or materials the nondiscrimination clause.
14. We agree not to use subcontractors, vendors or suppliers on State contracts who are reported to be in noncompliance or unawardable by a State agency Contract Compliance Officer.
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
................
................
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