Form GSA 527 GSA 527 Contractor's Qualifications and Financial Information

OMB No.: 3090-0007
Expires:
7/31/2012

CONTRACTOR'S QUALIFICATIONS AND FINANCIAL INFORMATION

Public reporting burden for this collection of information is estimated to average 2.5 hours per response, including the time for reviewing instructions, searching existing data sources,
gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this
collection of information, including suggestions for reducing this burden, to the Financial Information Control Division (BCD), Office of Finance, GSA, Washington, DC 20405; and to
the Office of Management and Budget, Paperwork Reduction Project (3090-0007), Washington, DC 20503.

SECTION I - GENERAL INFORMATION
1A. NAME

2. TYPE OF ORGANIZATION (Check one)

1B. STREET ADDRESS
1C. CITY

1D. STATE

1E. ZIP CODE

A. SOLE PROPRIETORSHIP

F. LIMITED LIABILITY COMPANY

B. GENERAL PARTNERSHIP

G. JOINT VENTURE

C. LIMITED PARTNERSHIP

H. TRUST

D. CORPORATION

I. OTHER (Specify below)

E. SUBCHAPTER S CORPORATION
3. TAXPAYER ID NUMBER

4. DATE ORGANIZATION ESTABLISHED

6. TRADE STYLE NAME (Provide a copy of filing)

7. KIND OF PRODUCT OR SERVICE PROVIDED

8. FORMER BUSINESS NAME

5. STATE OF INCORPORATION

10. INVENTORY VALUATION METHOD
A. LIFO

9. KIND OF BUSINESS
A. MANUFACTURER

D. RETAILER

B. CONTRACTOR

E. OTHER (Specify)

C. AVERAGE COST
D. OTHER (Specify)

B. FIFO

C. WHOLESALER

11. OWNERSHIP INFORMATION-PARTNERS-PRINCIPAL STOCKHOLDERS-OTHERS
TITLE
(If partner, state G(General) or L(Limited) in column)
NAME
ACTUAL TITLE

G OR L

% BUSINESS
OWNED

13. IF "YES" TO ANY QUESTION BELOW, PROVIDE DETAILED
INFORMATION IN SECTION VIII, REMARKS

12. PARENT COMPANY (If applicable)
A. NAME

YES

NO

A. HAVE YOU, OR ANY OF YOUR AFFILIATES EVER FILED FOR BANKRUPTCY?
B. DO YOU HAVE ANY JUDGMENTS, LIENS, OR PENDING SUITS?
C. STATE C. DO YOU HAVE ANY CONTINGENT LIABILITIES?

B. CITY

D. HAVE YOU OR ANY OF YOUR AFFILIATES DISC. BUSINESS OPER. W/OUTSTANDING DEBTS?

SECTION II - GOVERNMENT FINANCIAL AID AND INDEBTEDNESS
14A. ARE YOU DELINQUENT ON ANY FEDERAL DEBT (OMB CIRCULAR A-129)
(If "Yes", provide detailed information, Section VIII, Remarks)
14B. DO YOU OWE THE
GOVERNMENT
FOR ANY
CONTRACT OR
OTHER CLAIMS?

YES

IF "YES", COMPLETE THE ITEMS BELOW
AGENCY

CLAIM AMOUNT

PAYMENT

YES
NO
15A. AGENCY INVOLVED WITH DELINQUENCY
16. ARE YOU
CURRENTLY
RECEIVING
GOVERNMENT
FINANCING?
YES

NO

MATURITY

BALANCE

15B. AMOUNT OF DELINQUENCY ($)
17. COMPLETE ITEMS BELOW IF APPLICABLE

TYPE OF FINANCING

AUTHORIZED ($)

IN USE ($)

GOVERNMENT AGENCY INVOLVED

A. INDUSTRIAL REVENUE BONDS
B. GUARANTEED LOANS
C. ADVANCED PAYMENTS
D. PROGRESS PAYMENTS

NO (Go to Section III )

E. OTHER (Specify)

GENERAL SERVICES ADMINISTRATION

GSA FORM 527 (REV. 3-99)

SECTION III - FINANCIAL STATEMENTS
Prepared Financial Statements with notes may be provided in lieu of completing Section III
When financial statements are prepared or certified by independent accountants and transcribed to
this form, please furnish the name and address of accountant of accounting firm.
19A. NAME

18. ARE YOU THE INCUMBENT CONTRACTOR FOR THIS SOLICITATION?
YES

NO

20. IF TRANSCRIBED STATEMENTS DIFFER FROM INDEPENDENT ACCOUNTANT'S,
PLEASE DESCRIBE ADJUSTMENT IN SECTION VII, REMARKS. ALL OF THE
LISTED FIGURES ARE:

19B. STREET ADDRESS
19C. CITY

19D. STATE 19E. ZIP CODE

ACTUAL

U.S. DOLLARS

IN THOUSANDS

FOREIGN CURRENCY (Specify)

IN MILLIONS
21. BALANCE SHEET AS OF (Month, Day, Year)

23. PREPARED STMTS.

22. FISCAL YEAR ENDS (Month, Day, Year)

ARE ATTACHED

24. ASSETS
A. Current Assets

25. LIABILITIES AND NET WORTH
A. Current Liabilities

Cash
Short Term cash investments
Accounts receivable, less allowance for
doubtful accounts of $
Inventories
Other current assets (Itemize below)

Accounts payable
Notes payable (current)
Current portion of long term debt
Accrued expenses
Accrued taxes on income/excess profits
Other current liabilities (Itemize)

Total Current Liabilities

Total Current Assets
B. Property, Plant and Equipment
Land
Buildings and equipment
Leasehold improvements
Less accumulated depreciation and
amortization
Total Property, Plant and Equipment
C. Other Assets
Investments in and advance to affiliated
company
Goodwill, less amortization
Due from officer, employee
Other (Itemize)

Total Other Assets
D. TOTAL ASSETS
26. FROM (Month, Day, Year)

B. Other Liabilities
Mortgages
Bonds
Deferred income taxes
Other long term debt
Total Other Liabilities
Total Liabilities
C. Minority Interest in Subsidiary
D. Net Worth
Preferred stock
Common stock
Additional paid-in capital
Retained earnings/owner's equity
Less, Treasury stock
Total Net Worth
E. TOTAL LIABILITIES AND NET WORTH
SECTION IV - INCOME STATEMENT

27. TO (Month, Day, Year)

28. INCOME
A. Net Sales
Cost and Expenses
Cost of Goods Sold
Depreciation and Amortization
Selling, General, and Admin. Expenses
Interest Expense
Other Expenses (Itemize)

Minority Interest in Earnings of
Subsidiaries
Total Costs and Expenses
Earnings Before Taxes
Taxes on Income
Income Before Extraordinary Items
Extraordinary Gains (Losses) Net of Taxes
NET INCOME (LOSS)
GSA FORM 527 (REV.3-99) PAGE 2

SECTION V - BANKING AND FINANCE COMPANY INFORMATION
(Please attach a separate sheet using this format for any additional banks.)
ITEM

BANK 1

BANK 2

29. Name of Bank
30. Contact Person
31. Phone Number
32. Fax Number

AREA CODE

NUMBER

AREA CODE

NUMBER

EXT.

STREET ADDRESS

33. Address

CITY

AREA CODE

NUMBER

AREA CODE

NUMBER

EXT.

STREET ADDRESS
STATE

ZIP CODE

CITY

STATE

ZIP CODE

34. Amount Owing ($)
35. Term Loans

Yes

No

Yes

No

36. Line of Credit

Yes

No

Yes

No

37. Maximum Amount
Authorized ($)
38. Amount
Outstanding ($)

39. Loans Secured by Company's Assets - Real and Personal Property
SECURED PARTY NAME

A.

CONTACT NAME

STREET ADDRESS

CITY

STATE

SECURING ASSETS

MATURITY DATE

SECURED PARTY NAME

B.

STREET ADDRESS

CITY

STATE
MATURITY DATE

SECURED PARTY NAME
STREET ADDRESS

CITY

MONTHLY PAYMENT ($)

STATE
MATURITY DATE

SECURED PARTY NAME

ZIP CODE

MONTHLY PAYMENT ($)

CONTACT NAME

STREET ADDRESS

CITY

SECURING ASSETS

STATE
MATURITY DATE

40. ARE ANY OF THE ASSETS SHOWN ON THE BALANCE SHEET
PLEDGED OR MORTGAGED, EXCEPT AS STATED ABOVE?

NO

ZIP CODE

CONTACT NAME

SECURING ASSETS

D.

MONTHLY PAYMENT ($)

CONTACT NAME

SECURING ASSETS

C.

ZIP CODE

YES (Explain in Section VII, Remarks)

ZIP CODE

MONTHLY PAYMENT ($)

41A. IF CONTRACTOR IS A PARTNERSHIP OR SOLE PROPIERTORSHIP, ARE 41B. TOTAL
THE INDIVIDUAL LIABILITIES OF THE PROPIETOR(S) FOR FEDERAL
LIABILITY ($)
AND STATE INCOME AND/OR EXCESS PROFIT TAXES INCLUDED ON
THE BALANCE SHEET?
YES
NO

42. ARE YOU NOW IN OR PENDING DEFAULT ON ANY OBLIGATIONS, I.E., BANKS, FINANCIAL INSTITUTIONS, SUPPLIERS, OTHER?
NO

YES (Provide detailed information in Section VII, Remarks)

GSA FORM 527 (REV. 3-99) PAGE 3

SECTION VI - PRINCIPAL MERCHANDISE OR RAW MATERIAL SUPPLIER INFORMATION
(Please attach separate sheet(s) using this format for additional suppliers.)
43. PAST DUE ACCOUNTS PAYABLE ($)

ITEM

44. SUPPLIER 1

45. SUPPLIER 2

A. Name of Supplier
B. Contact Person
C. Telephone
D. Fax

AREA CODE

NUMBER

AREA CODE

NUMBER

EXT.

STREET ADDRESS

E. Address

AREA CODE

NUMBER

AREA CODE

NUMBER

EXT.

STREET ADDRESS

CITY

STATE

ZIP CODE

CITY

STATE

ZIP CODE

F. Amount Now
Owing ($)
G. High Credit ($)

ITEM

46. SUPPLIER 3

47. SUPPLIER 4

A. Name of Supplier
B. Contact Person
C. Telephone
D. Fax

AREA CODE

NUMBER

AREA CODE

NUMBER

EXT.

STREET ADDRESS

E. Address

CITY

AREA CODE

NUMBER

AREA CODE

NUMBER

EXT.

STREET ADDRESS
STATE

ZIP CODE

CITY

STATE

ZIP CODE

F. Amount Now
Owing ($)
G. High Credit ($)

SECTION VII - CONSTRUCTION/SERVICE CONTRACTS INFORMATION (Public Buildings Service Contracts Only)
CONTRACTS IN FORCE
ITEM

48. CONTRACT 1

49. CONTRACT 2

A. Location
B. Owner's Name
STREET ADDRESS

C. Address

CITY

STREET ADDRESS
STATE

ZIP CODE

CITY

STATE

ZIP CODE

D. Type of Work
E. Contract Amt. ($)
F. % Completed
G. Est. Comp. Date

ITEM

50. CONTRACT 3

51. CONTRACT 4

A. Location
B. Owner's Name
STREET ADDRESS

C. Address

CITY

STREET ADDRESS
STATE

ZIP CODE

CITY

STATE

ZIP CODE

D. Type of Work
E. Contract Amt. ($)
F. % Completed
G. Est. Comp. Date

GSA FORM 527 (REV. 3-99) PAGE 4

ITEM

52. CONTRACT 5

53. CONTRACT 6

A. Location
B. Owner's Name
STREET ADDRESS

C. Address

STREET ADDRESS

CITY

STATE

ZIP CODE

CITY

STATE

ZIP CODE

D. Type of Work
E. Contract Amt. ($)
F. % Completed
G. Est. Comp. Date

ITEM

54. CONTRACT 7

55. CONTRACT 8

A. Location
B. Owner's Name
STREET ADDRESS

C. Address

STREET ADDRESS

CITY

STATE

ZIP CODE

CITY

STATE

ZIP CODE

D. Type of Work
E. Contract Amt. ($)
F. % Completed
G. Est. Comp. Date

LARGEST JOBS YOU HAVE COMPLETED IN THE LAST FIVE YEARS
56. JOB 1
57. JOB 2

ITEM
A. Location
B. Contact's Name

STREET ADDRESS

C. Address

D. Telephone

STREET ADDRESS

CITY
AREA CODE

STATE
NUMBER

ZIP CODE
EXT.

CITY
AREA CODE

STATE
NUMBER

ZIP CODE
EXT.

E. Type of Work
F. Contract Amt. ($)
G. Amount Sublet ($)

ITEM

58. JOB 3

59. JOB 4

A. Location
B. Contact's Name
STREET ADDRESS

C. Address

D. Telephone

STREET ADDRESS

CITY
AREA CODE

STATE
NUMBER

ZIP CODE
EXT.

CITY
AREA CODE

STATE
NUMBER

ZIP CODE
EXT.

E. Type of Work
F. Contract Amt. ($)
G. Amount Sublet ($)

ITEM

60. JOB 5

61. JOB 6

A. Location
B. Contact's Name
STREET ADDRESS

C. Address

D. Telephone

STREET ADDRESS

CITY
AREA CODE

STATE
NUMBER

ZIP CODE
EXT.

CITY
AREA CODE

STATE
NUMBER

ZIP CODE
EXT.

E. Type of Work
F. Contract Amt. ($)
G. Amount Sublet ($)

GSA FORM 527 (REV. 3-99) PAGE 5

LIST COMPANIES FROM WHOM YOU OBTAIN SURETY BONDS
62. SURETY COMPANY 1
63. SURETY COMPANY 2

ITEM
A. Company Name
B. Contact's Name
C. Telephone
D. Fax

AREA CODE

NUMBER

AREA CODE

NUMBER

EXT.

STREET ADDRESS

E. Address

NUMBER

AREA CODE

NUMBER

EXT.

STREET ADDRESS

CITY

64. PRESENT AMOUNT OF BONDING
COVERAGE ($)

AREA CODE

STATE

ZIP CODE

CITY

STATE

ZIP CODE

65. HAS YOUR APPLICATION FOR SURETY
66. DURING THE PAST 2 YEARS, HAVE YOU BEEN CHARGED WITH A
FAILURE TO MEET THE CLAIMS OF YOUR SUBCONTRACTORS OR
BOND EVER BEEN DECLINED? (If Yes,
SUPPLIERS? (If Yes, please provide detailed information in Remarks)
please provide detailed information in Remarks)
YES

NO

YES

NO

SECTION VIII - REMARKS

REMARKS (Cite those sections of the form relating to your remarks. If additional space is required, attach additional sheet(s).)

CERTIFICATION
For the purpose of establishing financial responsibility with, or procuring credit from the General Services Administration, we furnish the above
as a true and correct statement of our financial condition and further certify that all other statements are true and correct. There has been no
material change in the applicant's financial condition since the date of the above statement. We agree to notify you immediately in writing of
any materially unfavorable change in our financial condition. In the absence of such notice or of a new and full financial statement, this is to be
considered as a continuing statement.
NAME OF BUSINESS

BY (Signature of Authorized Official)

NAME OF AUTHORIZED OFFICIAL (Type or print)

DATE

TITLE OF AUTHORIZED OFFICIAL (Type or print)

GSA FORM 527 (REV. 3-99) PAGE 6