APPENDIX B.11

NEW YORK CITY TRANSIT AUTHORITY

Division of Materiel

Procurement Sub-Division

Schedule J

BIDDER'S QUALIFICATION QUESTIONNAIRE

PART I - INSTRUCTIONS

1	a.	All Bidders/Proposers submitting a Bid/Proposal for public work contracts (IFB & RFP); personal service (including Architectural and Engineering) contracts (RFP); RFPs for supply, material, equipment (including transit vehicles and rolling stock); RFPs for miscellaneous procurement and service contracts; non-competitive/sole source contracts (including preferred source and existing public contracts) equal to or in excess of $10,000 are to complete and submit Parts I, II, III, IV and VIII with their Bid or Proposal.

b.	PUBLIC WORK CONTRACTS (IFB & RFP)

If this Questionnaire is submitted in response to an Information for Bidders (IFB), the apparent low bidder will receive written notification requesting submission of Parts V, VI and VII. If this Questionnaire is submitted in response to a Request for Proposal (RFP), and the proposal submitted equals or exceeds $25,000 all Proposers are to complete and submit all Parts of the Questionnaire with their Proposal.

c.	PERSONAL SERVICE INCLUDING ARCHITECTURAL AND ENGINEERING CONTRACTS (RFP)

Where the proposal submitted equals or exceeds $20,000 for a personal service (consultant) contract, all Proposers are to complete and submit all Parts of the questionnaire with their Proposal.

d.	RFPs FOR SUPPLY, MATERIAL, OR EQUIPMENT (INCLUDING TRANSIT VEHICLES AND ROLLING STOCK), AND MISCELLANEOUS PROCUREMENT AND SERVICE CONTRACTS

Where the proposal submitted equals or exceeds $250,000 for supplies, materials, or equipment (including transit vehicles and rolling stock), and miscellaneous procurement and service contracts all Proposers are to complete and submit all Parts of the questionnaire with their Proposal.

e.	NON-COMPETITIVE/SOLE SOURCE CONTRACTS (INCLUDING PREFERRED SOURCE AND EXISTING PUBLIC CONTRACTS

Where the proposal submitted equals or exceeds $25,000 for non-competitive public work contracts, $20,000 for non-competitive personal service (Consultant) contracts, and $250,000 for all other non-competitive contracts, all Proposers are to complete and submit all Parts of the questionnaire with their Proposal.

2.	Please state "not applicable" in questions clearly not applicable to Bidder/Proposer in connection with this solicitation. Do not omit any question. If any representation is not accurate and complete at the time Bidder/Proposer signs this Questionnaire, Bidder/Proposer must, as part of its Bid/Proposal, identify the provision and explain the reason in detail in the space provided below. If additional space is needed, add additional sheet(s) to this Questionnaire. If this space is left blank, Bidder/Proposer shall be deemed to have represented and warranted the accuracy and completeness of the representations on this Questionnaire:

3.	All information must be legible.

4.	Completed Questionnaire must be sworn to by a partner (if partnership), a duly authorized officer or individual (if a corporation), or a principal (if a sole proprietorship).

5.	The term "Proposer" includes the term "Bidder" and also refers to the firm awarded the Contract. The term "Proposal" includes the term "Bid".

6.	If during the performance of this Contract, either of the following occurs, Bidder shall promptly give notice in writing of the situation to the Authority's Chief Procurement Officer, and therefore cooperate with the Authority's review and investigation of such information.

i)	Proposer has reason to believe that any representation or answer to any question contained in this Questionnaire was not accurate or complete at the time this Questionnaire was signed; or

ii)	events occur or circumstances changes so that an answer to any question in Part IV is no longer accurate or complete.

In the Authority's sole discretion, the following shall constitute grounds for the Authority to take remedial action up to and including immediate termination of the Contract for convenience without payment for profit and overhead for work not performed if: i) Proposer fails to notify the Chief Procurement Officer as required by "6" above: ii) Proposer fails to cooperate with the Authority's request for additional information as required by "6" above.

7.	The Authority reserves the right to inquire further with respect to Proposer's responses; and Proposer consents to such further inquiry and agrees to furnish all relevant documents and information as requested by the Authority. Any response to this document prior or subsequent to Proposer's Proposal which is or may be construed as unfavorable to Proposer will not necessarily automatically result in a negative finding on the question of Proposer's responsibility or a decision to terminate the Contract if it is awarded to Proposer.

PART II - IDENTITY OF PROPOSER

1.	Proposer's Full Legal Name:

2.	The Proposer represents that it operates as the following form of legal entity: (Check whichever applies and fill in any appropriate blanks.)

an individual or sole proprietorship

a general partnership

a limited partnership

a joint venture consisting of:

and

(List all joint venturers on a separate sheet if this space is inadequate.)

a non-profit organization

a corporation organized or incorporated under the laws of the following state or country:

on the following date:

3.	Proposer's federal taxpayer identification number:

4.	Proposer's legal address:

Telephone Number: (____) _________________ Fax Number: (____)

5.	Proposer's local or authorized point of contract address:

Name:	Title:

Address:

Telephone Number: (____) _________________ Fax Number: (____)

6.	a.	If Proposer is a corporation, has a Certificate of Incorporation been previously filed with the New York City Transit Authority?

YES	NO	If answer is "NO", attach a certified copy.

b.	Attach a certified copy of the By-Laws and Resolution of the Corporation giving the names and titles of the corporate officers other than President, as well as non-officer employees, who are authorized to sign contracts, bonds, bills of sale and other legal instruments in connection with the Contract, if the same have not been previously filed.

c.	If a foreign corporation, has proof of authority to transact business in the State of New York been previously filed with the New York City Transit Authority?

YES	NO	If answer is "NO", attach proof of such authority.

In the event that any of Proposer's previous submissions to the Transit Authority in response to the above (questions a-c) no longer represent the Proposer's current corporate status, Proposer must attach a certified copy of any documents amending its previous submissions.

7.	a.	How long has the Proposer been in business?

b.	Have Proposer's major shareholders, officers or principals been in business under another name? If so, identify name and dates used.

c.	How many years experience as a prime contractor/consultant? ___________________________

d.	How many years experience as a subcontractor/subconsultant? __________________________

8.	List below the names, business addresses, titles, and telephone numbers of the following people: if a corporation, identify the president, executive officers, and any other officers directly responsible for this Proposal; if a partnership, identify the partners directly responsible for this Proposal; or, if another form of business entity, identify the principals directly responsible for this Proposal.

Name	Address	Title	Telephone No.

9.	If your firm considers itself to be an MBE, WBE or DBE, then within the past three years has the Proposer had any MBE, WBE, or DBE certification (or application for such certification) revoked or, if you made application for such certification during such period was same denied?

YES	NO If answer is "YES", explain:

PART III-PROPOSER'S REPRESENTATIONS

I.	By submission of this Proposal, the undersigned and each person signing on behalf of the undersigned certifies, and in the case of a joint proposal each party thereto certifies, as to its own organization, as required by Section 2878 of the Public Authorities Law of the State of New York, under penalty of perjury, that to the best of its knowledge and belief:

a.	the prices in this Proposal have been arrived at independently without collusion, consultation, communication, or agreement for the purpose of restricting competition, as to any matter relating to such prices with any other proposer or with any competitor;

b.	unless otherwise required by law, the prices which have been quoted in this Proposal have not been knowingly disclosed by the Proposer arid will not knowingly be disclosed by the undersigned prior to opening, directly or indirectly, to any other proposer or to any competitor prior to the closing date for proposals;

c.	no attempt has been or will be made by the Proposer to induce any other person, partnership or corporation to submit or not to submit a proposal for the purpose of restricting competition;

A Proposal shall not be considered for award nor shall any award be made where a, b, and c, above, have not been complied with provided, however, that if in any case the Proposer cannot make the foregoing certification, the Proposer shall so state and shall furnish with the Proposal a signed and notarized statement which sets forth in detail the reasons therefor. Where a, b, and c, above, have not been complied with, the Proposal shall not be considered for award nor shall any award be made unless the Vice President, Division of Materiel of the Authority, or his/her designee, determines that such disclosure was not made for the purpose of restricting competition.

The fact that a Proposer (i) has published price lists, rates, or tariffs covering items being procured; (ii) has informed prospective customers of proposed or pending publication of new or revised price lists for such items; or (iii) has sold the same items to other customers at the same prices being proposed, does not constitute, without more, a disclosure within the meaning of a, b, and c above

2.	Statement of no-conflict of interest

a.	No appointed or elected official, member or other officer or employee of the City or State of New York, or of the Metropolitan Transportation Authority ("MTA"), or MTA's affiliates arid subsidiaries which consist of the New York City Transit Authority, Manhattan & Bronx Surface Transit Operating Authority, Staten Island Rapid Transit Operating Authority, Metro-North Commuter Railroad, Long Island Rail Road, Triborough Bridge and Tunnel Authority, Metropolitan Suburban Bus Authority, and Metropolitan Transportation Authority Card Company: i) is interested directly or indirectly, in any manner whatsoever in or in the performance of the Contract or in the supplies, work or business to which it relates or in any portion of the profits thereof; or ii) has been or will be offered or given any tangible consideration in connection with this Proposal/Contract.

b.	Proposer covenants that neither Proposer nor, to the best of the Proposer's knowledge after diligent inquiry, any director, officer, owner or employee of the Proposer has any interest nor shall they acquire any interest, directly or indirectly, which would conflict in any manner or degree with the faithful performance of the Contract hereunder.

c.	In the event Proposer has no prior knowledge of a conflict of interest as set forth in "a" and "b" above and hereafter acquires information which indicates that there may be an actual or apparent violation of any of the above, Proposer shall promptly bring such information to the attention of the Authority's Chief Procurement Officer, Proposer shall thereafter cooperate with the Authority's review and investigation of such information, and comply with any instruction it receives from the Chief Procurement Officer in regard to remedying the situation.

3.	The following statements apply to any proposal or contract between Proposer and the City or State of New York, any other state, any public authority or other public entity, the United States government, the Metropolitan Transportation Authority ("MTA"), and MTA's affiliates and subsidiaries which are the New York City Transit Authority, Manhattan & Bronx Surface Transit Operating Authority, Staten Island Rapid Transit Operating Authority, Metro-North Commuter Railroad, Long Island Rail Road, Triborough Bridge and Tunnel Authority, Metropolitan Suburban Bus Authority, and Metropolitan Transportation Authority Card Company.

a.	Statements b, c, d. e, f and g below also apply to i) Proposer's parent, subsidiaries and affiliates (if any), ii) any joint venture (including its individual members and any other form of partnership (including its individual members) which includes Proposer or Proposer's parent, subsidiaries, or affiliates; iii) Proposer's directors, officers, principals, and managerial employees and any person or entity with a 10% or more interest in Proposer; iv) any legal entity controlled, or 10% or more of which is owned, by Proposer, or by any director, officer, principal or managerial employee of Proposer, or by any person or entity with a 10% or more interest in Proposer; or v) any parent, subsidiary or affiliate of any legal entity controlled, or 10% or more of which is owned, by Proposer, or by any director, officer, principal or managerial employee of Proposer, or any person or entity with a 10 % or more interest in Proposer.

b.	Has the Proposer been declared not responsible. (Check "YES" or "NO", as appropriate.)

YES	NO

c.	Has the Proposer been debarred, suspended, proposed for debarment, declared ineligible, voluntarily excluded, or otherwise disqualified from bidding, proposing, or contracting. (Check "YES" or "NO", as appropriate.)

YES	NO

d.	Has the Proposer been a defaulter, as principal, surety or otherwise. (Check "YES" or "NO", as appropriate.)

YES	NO

e.	Has the government or other public entity requested or required enforcement of any of its rights under a surety agreement on the basis of a Proposer default or in lieu of declaring Proposer in default. (Check "YES" or "NO", as appropriate.)

YES	NO

f.	Is the Proposer in arrears upon a contract or debt. (Check "YES" or "NO", as appropriate

YES	NO

g.	Are there any proceeding pending relating to Proposer's responsibility, debarment, suspension, voluntarily exclusion or qualification to receive a public contract. (Check "YES" or "NO". as appropriate.)

YES	NO

h.	List the name and business address of each person or legal entity which has a 10% or more ownership or control interest in Proposer (attach additional pages as needed).

i.	Explain any "YES" answers to b, c, d, e, f and g in the space provided below (attach additional pages as needed).

PART IV - QUESTIONS WHICH MUST BE ANSWERED "YES" OR "NO"

(In the event of a "YES", the Authority reserves the right to inquire further with respect thereto.)

To the best of your knowledge after diligent inquiry, in connection with the business of proposer or any other firm which is related to Proposer by any degree of common ownership, control, or otherwise, do any of the following statements apply to: i) Proposer; ii) Proposer's parent; iii) any Proposer subsidiary or affiliate; iv) any joint venture (including its individual members) or any other partnership (including its individual members) which includes Proposer or Proposer's parent, subsidiaries, or affiliates, v) any legal entity, or parent, subsidiary or affiliate of any legal entity, controlled. or 10% or more of which is owned, by Proposer, or by any director, officer, principal or managerial employee of Proposer, or by any person or entity with a 10% or more interest in Proposer. or vi) any person who is a director, officer, principal, or, managerial employee, or person or entity with a 10% or more interest in any of the aforesaid:

1	Has been convicted by a plea or verdict of guiltily of, or pleaded nolo contendere to, a misdemeanor or felony in any federal, state or local court. (Check "YES" or "NO", as appropriate.)

YES	NO

2	Have pending any state or federal grand jury or court an indictment or information for the commission of a crime which has riot been favorably,' terminated. (Check "YES" or "NO", as appropriate.)

YES	NO

3.	Is the subject of any pending investigation by any grand jury, commission, committee or other entity or agency or authority of any state or the federal government in connection with the commission of a crime. (Check "YES" or "No", as appropriate.)

YES	NO

4.	Is currently disqualified from selling or submitting bids/proposals to or receiving awards from or entering into any contracts with any federal, state or local governmental entity, any public authority or any public entity (Check "YES" or "NO", as appropriate.)

YES	NO

5.	Within the past five years,. has refused to testify or to answer any question concerning a bid or contract with any federal, state, or local governmental entity, any public authority or other public entity when called before a grand jury or other committee, agency or forum which is empowered to compel the attendance of witnesses and examine them under oath, upon being advised that neither the person's statement nor any information or evidence derived from such statement will be used against that person in any subsequent criminal proceeding. (Check "YES" or "NO" as appropriate.)

YES	NO

6.	Is currently disqualified from selling or submitting a bid to, or receiving an award from, or entering into any contract with any public entity or public authority within the State of New York because, within the past five years, such entity or person refused to testify or to answer any relevant question concerning a transaction or contract with the State of New York, any political subdivision of the State of New York, or a public authority or a public department, agency or official of the State of New York or of a political subdivision of the State of New York, when called before a grand jury or other state or local department, commission or agency which is empowered to compel the attendance of witnesses and examine them under oath. upon being advised that neither that person's statement nor any information or evidence derived from such statement will be used against that person in any subsequent criminal proceeding, (Check "YES" or "NO", as appropriate.)

YES	NO

7.	Has within a three year period preceding this Proposal been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain. or performing a public (Federal, State or local) transaction or contract under a public transaction; violation of Federal or State antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property. (Check "YES" or "NO", as appropriate.)

YES	NO

8.	Explain any "YES" answers to 1, 2, 3, 4, 5, 6 or 7, in the space provided below (attach additional pages as needed).

PART V-TECHNICAL

1.	List the name, title and business address of each director and principal officer of Proposer.

2.	Number of employees: _______________ including ____________ employees in the Greater New York Metropolitan Area.

3.	Does the Proposer have any outstanding bids or proposals for contracts (i.e., bids or proposals pending where no contract has yet been awarded) with the State or City of New York, or any other public authority of the State of New York, or the Metropolitan Transportation Authority ("MTA"), and MTA's affiliates and subsidiaries which are the New York City Transit Authority, Manhattan & Bronx Surface Transit Operating Authority, Staten Island Rapid Transit Operating Authority, Metro-North Commuter Railroad, Long Island Rail Road, Triborough Bridge and Tunnel Authority, Metropolitan Suburban Bus Authority, and Metropolitan Transportation Authority Card Company? If none, state "None". If yes, please list them and provide the name of the requesting agency, the contract number, a brief description of the work effort and the status of the bid or proposal. Indicate if the bid/proposal was submitted by the Bidder as prime contractor or joint venture.

4.	Has the Proposer been awarded any contracts within the last three years by the State or City of New York, or any other public authority of the State of New York, or the Metropolitan Transportation Authority ("MTA"), and MTA's affiliates and subsidiaries which are the New York City Transit Authority, Manhattan & Bronx Surface Transit Operating Authority, Staten Island Rapid Transit Operating Authority, Metro-North Commuter Railroad, Long Island Rail Road, Triborough Bridge and Tunnel Authority, Metropolitan Suburban Bus Authority, and Metropolitan Transportation Authority Card Company? If none, state "None". If yes, describe those contracts beginning with the most recent. State the name of the contracting entity; give a brief description of the contract and the contract number; state the contract period, the status of the contract, and the name, address, and telephone number of a contact person at the agency. Indicate if award was made to Proposer as prime contractor or joint venture. Proposer need not provide more than six such descriptions.

5.	Does the Proposer have any current private sector projects? If none, state "None". If yes, provide name and address of owner, a brief description of work, status of contracts and name, address and telephone number of contact person as to each, beginning with the most recent. Indicate if Proposer is acting as prime contractor or joint venture. Proposers need not provide more than six such descriptions.

6.	For each of the following contracts, provide a brief description of the work performed, the contract number, the dollar amount at award and at completion, date completed, and the name and telephone number of the owner's representative.

a.	Each contract completed during the last three years or, if less than three contracts have been completed during the last three years, list the last three contracts completed.

b.	Each contract completed during the last three years or, if less than three contracts have been completed during the last three years, list the last three contracts completed, for which liquidated damages or penalty provisions were assessed against you for failure to complete the work on time or for any other reason.

7.	List each contract which, during the last three years, the person/entity contracting with you: i) terminated for default; ii) sued to compel performance; iii) sued to recover damages, including, without limitation, upon alleged breach of contract, misfeasance, error or omission or other alleged failure on your part to perform as required by your contract; or iv) called upon a surety to perform the work.

8.	Describe whether any present or anticipated commitments and/or contractual obligations might have an influence on the capabilities of the Proposer to perform the work called for by this Contract. Any apparent conflicts as between the requirements/commitments for this Contract and the matters listed in items 3, 4, 5 or 6, above, with respect to the use of Proposer's resources, such as management or technical expertise or financing, should be explained. If none, state "None".

9.	Describe any litigation in which the Proposer is involved, which:

a.	has or may have an impact on the Proposer's ability to perform any work called for by this solicitation; or

b.	the demand or potential exposure is for more than $250,000, exclusive of personal injury litigation where the liability is covered by insurance.

If none, state "None."

10.	During the past three years, has the Proposer's firm ever been a party to a bankruptcy or reorganization proceeding?

YES	NO If answer is "YES" explain below.

11.	a.	If any professional or other licenses, permits, or certifications are required to perform the work/services called for by this solicitation, list the license, permit, or certification that the Proposer or Proposer's employees or agents possess. If none, state "None".

License or Permit	Issuing

or Certification	Name of Holder	State or Entity

b.	Have any of the Proposer's officers, partners, owners, managers or employees had any project related licenses, permits or certifications revoked or suspended in the past three years.

YES	NO	If answer is "YES", explain details below.

12.	Does the Proposer's firm share office space, staff or equipment (including telephone exchanges) with any other business or organization?

YES	NO	If answer is "YES", list firm name, address and nature of shared facilities.

13.	Has Proposer's safety practices/procedures been evaluated or rated as less then satisfactory by the City or State of New York, any other state, any public authority or other public entity, the United States government, the Metropolitan Transportation Authority ("MTA"), and MTA's affiliates and subsidiaries which are the New York City Transit Authority, Manhattan & Bronx Surface Transit Operating Authority, Staten Island Rapid Transit Operating Authority, Metro-North Commuter Railroad, Long Island Rail Road, Triborough Bridge and Tunnel Authority, Metropolitan Suburban Bus Authority, and Metropolitan Transportation Authority Card Company within the past five years?

YES	NO	If answer is "YES", explain details below.

14.	Is your firm's Workers Compensation Experience Rating 1.2 or greater?

YES	NO	If answer is "YES", explain details below.

15.	Does Proposer have either a history of claims loss or any substantial individual claim loss within the past five years due to general liability or workers compensation claims?

YES	NO	If answer is "YES", explain details below.

16	List the names, titles and attach resumes which indicate the record of skill and experience of your proposed project management team. (See Specifications or the Scope - of - Work for the functions of the project management team, as applicable, and other requirements in regard to project management.)

17.	Which of the individuals named in item 16, above, will be utilized exclusively on this Contract on a full-time basis? (The Specification or the Scope - of - Work may indicate requirements for certain dedicated staff.)

18	Which of the individuals named in item 16, above, are not presently officers, partners. owners or employees of the firm?

19	Attach an outline of your proposed Quality Control program (see appropriate section of the Specifications or the Scope - of Work) for this Contract. Where the Specifications or the Scope-of-
Work set out required elements for the program, such outline must cover each element.

PART IV - ADDITIONAL QUESTIONS

1.	List all Proposer's employees:

a.	who are currently employees of the Metropolitan Transportation Authority ("MTA"), or any MTA subsidiary or affiliate (New York City Transit Authority, Manhattan & Bronx Surface Transit Operating Authority, Staten Island Rapid Transit Operating Authority, Metro-North Commuter Railroad, Long Island Rail Road, Triborough Bridge and Tunnel Authority, Metropolitan Suburban Bus Authority, and Metropolitan Transportation Authority Card Company).

b.	who within the past two years have been MTA or MTA subsidiary or affiliate employees who were involved on behalf of Proposer with the preparation of this Proposal or would be involved in the performance of the Contract if it is awarded to Proposer.

2.	Does Proposer have a subsidiary or affiliate?

YES	NO	If answer is "YES", list firm name, address and affiliation

3.	Is Proposer a subsidiary of another entity?

YES	NO If answer is "YES", list firm name, address and affiliation

4.	Does Proposer, any director, officer, principal or managerial employee of Proposer, or any other person or entity with a 10% or more interest in Proposer have an interest of 10% or more in any other firm or legal entity?

YES	NO If answer is "YES", list individuals name and firm or entity

5.	If the answer to 2, 3 or 4 is "YES", would Proposer's answers pertaining to Parts III and IV be the same for each such parent, subsidiary, affiliate, firm or legal entity?

YES	NO If answer is "NO", explain below

PART VII - FINANCIAL

1.	Provide certified financial statements for the last three fiscal years. If certified financial statements are not available, provide financial statements sworn to by the firm's Chief Financial Officer.

2.	The Proposer may submit its prior 3 years' financial statements in lieu of completing Section 1 (Balance Sheet), Section 2 (Comparative Statement of Income & Retained Earnings), and Section 3 (Comparative Statements of Cash Flows). However, Section 1, Schedules A, B, C, D, E and F and Sections 4, 6 and 7 must be completed. If the Proposer is required to submit a performance bond, Section 5 must also be completed.

SECTION 1

COMPARATIVE BALANCE SHEET

as of

($000)	19___	19___	19___

$	$	$

I.	CURRENT ASSETS:

Cash ___________________________	_________	_________	__________

Marketable Securities ______________	_________	_________	__________

Notes Receivable (Schedule A) _______	_________	_________	__________

Accounts Receivable (Schedule B) ____	_________	_________	__________

Bid Deposits (Schedule C) __________	_________	_________	__________

Inventories ______________________	_________	_________	__________

Prepaid Expenses _________________	_________	_________	__________

Other Current Assets:

________________________________	__________	_________	__________

________________________________	__________	_________	__________

________________________________	__________	_________	__________

________________________________	__________	_________	__________

________________________________	__________	_________	__________

TOTAL CURRENT ASSETS	$_________	$________	$_________

II.	OTHER ASSETS:

Investment in Affiliates ____________	$_________	$_________	$_________

Other Non-Current Assets:

________________________________	__________	__________	__________

________________________________	__________	__________	__________

________________________________	__________	__________	__________

TOTAL OTHER ASSETS	$_________	$_________	$_________

III.	PROPERTY, PLANT & EQUIPMENT:

NET PROPERTY, PLANT & EQUIPMENT

(Net of Depreciation)	$_________	$_________	$_________

TOTAL ASSETS	$_________	$_________	$_________

LIABILITIES

($000)	19___	19___	19___

$	$	$

I.	CURRENT LIABILITIES

Notes Payable (Schedule D) ________	__________	_________	__________

Accounts Payable (Schedule E) _____	__________	_________	__________

Loans Payable (Schedule F) ________	__________	_________	__________

Taxes Payable ___________________	__________	_________	__________

Current Portion of Long Term Debt __	__________	_________	__________

Accrued Liabilities _______________	__________	_________	__________

Other Current Liabilities:

________________________________	__________	_________	__________

________________________________	__________	_________	__________

________________________________	__________	_________	__________

________________________________	__________	_________	__________

________________________________	__________	_________	__________

TOTAL CURRENT LIABILITIES	$_________	$________	$_________

II.	NON-CURRENT LIABILITIES

Long Term Debt __________________	__________	_________	__________

Other:

________________________________	__________	_________	__________

________________________________	__________	_________	__________

________________________________	__________	_________	__________

TOTAL NON-CURRENT LIABILITIES	$_________	$________	$_________

TOTAL LIABILITIES	$_________	$________	$_________

III.	EQUITY

Capital Stock Paid Up:

Common ______________________	$_________	$_________	$_________

Preferred ______________________	$_________	$_________	$_________

Surplus (net worth) ________________	$_________	$_________	$_________

TOTAL EQUITY	$_________	$_________	$_________

TOTAL LIABILITIES AND EQUITY	$_________	$_________	$_________

DETAILS RELATIVE TO ASSETS

SCHEDULE A

(a) due within 90 days ____________$______________

Notes Receivable	(b) due after 90 days ____________$______________

(c) past due _____________________$______________

Receivable From:

Name	Purpose	Date of

Maturity	How

Secured	Amount
$
TOTAL	$

SCHEDULE B

Aging of Accounts Receivable	P A S T D U E

Current	1 to

30 days	31 to

60 days	61 to

90 days	Over

90 Days	Total
Trade $	$	$	$	$	$
Other $	$	$	$	$	$
Total $	$	$	$	$	$

SCHEDULE C

Bid Deposit

Holder of Deposit: Name	Description	Amount
$
TOTAL	$

DETAILS RELATIVE TO LIABILITIES

SCHEDULE D

Notes Payable

(a)	Not Past Due	__________________ $ _______________

(b)	Past Due	__________________ $ _______________
To Whom: Name	Purpose	When Due	Amount
$
TOTAL	$

SCHEDULE E

Accounts Payable

(a)	Not Past Due	__________________ $ _______________

(b)	Past Due	__________________ $ _______________
To Whom: Name	Purpose	Date

Payable	Amount
$
TOTAL	$

SCHEDULE F

Loans Payable

(a)	Not Past Due	__________________ $ _______________

(b)	Past Due	__________________ $ _______________
To Whom: Name	Purpose	Date

Payable	Amount
$
TOTAL	$

SECTION 2

COMPARATIVE STATEMENT OF INCOME & RETAINED EARNINGS

STATEMENT FOR PERIODS ENDED

19___	19___	19___

SALES___________________________	$________	$_________	$_________

Less:

COST OF SALES:

Labor _____________________	_________	_________	__________

Material ___________________	_________	_________	__________

Depreciation ________________	_________	_________	__________

Other Overhead _____________	_________	_________	__________

GROSS MARGIN	$________	$________	$_________

Less: Selling, General and

Administrative Expenses ______	_________	_________	__________

Income Before Taxes _________	_________	_________	__________

Less: Income Taxes __________	_________	_________	__________

NET INCOME	$________	$________	$_________

Retained Earnings Beginning

of Period _______________	$________	$________	$_________

Less: Cash Dividends Paid ____	$________	$________	$_________

Other:________________	$________	$________	$_________

Net Retained Earnings End

of Period ________________	$_________	$_________	$_________

SECTION 3

COMPARATIVE STATEMENTS OF CASH FLOWS

FOR THE YEARS ENDED

Increase (Decrease) in Cash

19___	19___	19___

Cash flows from operating activities:_______	$_________	$_________	$___________

Cash received from customers ____________	__________	_________	__________

Cash paid to suppliers & employees _______	__________	_________	___________

Interest Paid __________________________	__________	_________	___________

Income Taxes Paid _____________________	__________	_________	___________

Miscellaneous receipts (payments) ________	__________	_________	___________

____________________________________	__________	_________	___________

____________________________________	__________	_________	___________

____________________________________	__________	_________	___________

Net cash provided by operating. activities __	$_________	$________	$__________

Cash flows from investing activities:	__________	_________	___________

Proceeds from sale of equipment:__________	__________	_________	___________

Payments for purchase of equipment:_______	__________	_________	___________

_____________________________________	__________	_________	___________

_____________________________________	__________	_________	___________

_____________________________________	__________	_________	___________

Net Cash Used in Investing activities:_______	$_________	$________	$__________

Cash flows from financing activities:	__________	_________	___________

Net increase in short-term debt:	__________	_________	___________

Proceeds from issuance of long-term debt ___	__________	_________	___________

Repayment of long-term debt _____________	__________	_________	___________

Payment of Dividends ___________________	__________	_________	___________

_____________________________________	__________	_________	___________

_____________________________________	__________	_________	___________

_____________________________________	__________	_________	___________

Net Cash provided by (used in) financing

activities	$_________	$________	$__________

Net increase (decrease) in cash ____________	$_________	$________	$__________

Cash at beginning of year ________________	$_________	$________	$__________

Cash at end of year _____________________	$_________	$________	$__________

SECTION 4 - IDENTITY OF OWNERS

Who are the principal owners or shareholders of the business enterprise and approximately what percentage does each own?

Name	Percent Owned

SECTION 5 - PERFORMANCE BOND INFORMATION

Section 5 is only applicable to solicitations in which the Proposer is required to provide a performance bond.

Names and addresses of bonding company or companies that have agreed to furnish the performance bond required by the Contract.

Name	Address	Amount	Expiration Date
$

SECTION 6 - SUBCONTRACTS

What parts of this Contract, if any, does Proposer expect to subcontract?

Portion of Work	Name and Address of Proposed

Subcontractor, if known

SECTION 7 - CERTIFICATION

I certify that the attached financial statements for this Proposal properly reflect the financial position of the company for the periods indicated on the financials.

______________________________	________________

Chief Financial Officer	Date

PART VIII -VERIFICATION AND ACKNOWLEDGMENT

STATE OF _____________________________

COUNTY OF ___________________________

On the ______ day of _________________ 199__, before me personally came and appeared.

___________________________________________________ by me known to be said person, who swore under oath as follows:

1.	He/she is _____________________ of _______________________________________

(Print title)	(Print name of firm)

2.	He/she is duly authorizes to sign this Questionnaire on behalf of said firm and duly signed this document pursuant to said authorization.

3.	The answers to the questions set forth in this Questionnaire are true, accurate and complete.

4.	He/she acknowledged and understands that the Questionnaire includes provisions which are deemed included in the Contract if awarded to the firm.

Sworn to before me this ___________ day of ________________, 199__

_________________________________________

(Notary Public)