Fillable GSA Form 527 - SIN 246-54 Only July 2015 C:\PERFORM\GSA\G527.FRP

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GSA Form 527 - SIN 246-54 Only July 2015 C:\PERFORM\GSA\G527.FRP

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  • 58 check-boxes
  • 433 other fields

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File type: PDF

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CONTRACTOR'S QUALIFICATIONS AND FINANCIAL INFORMATION
OMB No.: 3090-0007
Expires: 8/31/2015
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
1B. STREET ADDRESS
1C. CITY 1D. STATE 1E. ZIP CODE
2. TYPE OF ORGANIZATION (Check one)
A. SOLE PROPRIETORSHIP
B. GENERAL PARTNERSHIP
C. LIMITED PARTNERSHIP
D. CORPORATION
E. SUBCHAPTER S CORPORATION
I. OTHER (Specify below)
3. TAXPAYER ID NUMBER 4. DATE ORGANIZATION ESTABLISHED 5. STATE OF INCORPORATION
6. TRADE STYLE NAME (Provide a copy of filing)
7. KIND OF PRODUCT OR SERVICE PROVIDED
8. FORMER BUSINESS NAME
D. RETAILER
E. OTHER (Specify)
B. FIFO
A. LIFO C. AVERAGE COST
D. OTHER (Specify)
11. OWNERSHIP INFORMATION-PARTNERS-PRINCIPAL STOCKHOLDERS-OTHERS
NAME
10. INVENTORY VALUATION METHOD
9. KIND OF BUSINESS
A. MANUFACTURER
B. CONTRACTOR
C. WHOLESALER
TITLE
(If partner, state G(General) or L(Limited) in column)
ACTUAL TITLE G OR L
% BUSINESS
OWNED
12. PARENT COMPANY (If applicable)
13. IF "YES" TO ANY QUESTION BELOW, PROVIDE DETAILED
INFORMATION IN SECTION VIII, REMARKS
YES NO
A. NAME
B. CITY C. STATE
A. HAVE YOU, OR ANY OF YOUR AFFILIATES EVER FILED FOR BANKRUPTCY?
B. DO YOU HAVE ANY JUDGMENTS, LIENS, OR PENDING SUITS?
C. DO YOU HAVE ANY CONTINGENT LIABILITIES?
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 NO
IF "YES", COMPLETE THE ITEMS BELOW
AGENCY CLAIM AMOUNT PAYMENT MATURITY BALANCE
15A. AGENCY INVOLVED WITH DELINQUENCY 15B. AMOUNT OF DELINQUENCY ($)
16. ARE YOU
CURRENTLY
RECEIVING
GOVERNMENT
FINANCING?
YES NO
YES
NO (Go to Section III )
17. COMPLETE ITEMS BELOW IF APPLICABLE
A. INDUSTRIAL REVENUE BONDS
B. GUARANTEED LOANS
C. ADVANCED PAYMENTS
D. PROGRESS PAYMENTS
AUTHORIZED ($) IN USE ($) GOVERNMENT AGENCY INVOLVED
E. OTHER (Specify)
GENERAL SERVICES ADMINISTRATION
GSA FORM 527 (REV. 3-99)
F. LIMITED LIABILITY COMPANY
G. JOINT VENTURE
H. TRUST
TYPE OF FINANCING
GSA FORM 527 (REV.3-99) PAGE 2
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.
18. ARE YOU THE INCUMBENT CONTRACTOR FOR THIS SOLICITATION?
NO
19A. NAME
19B. STREET ADDRESS
19C. CITY 19D. STATE 19E. ZIP CODE
20. IF TRANSCRIBED STATEMENTS DIFFER FROM INDEPENDENT ACCOUNTANT'S,
PLEASE DESCRIBE ADJUSTMENT IN SECTION VII, REMARKS. ALL OF THE
LISTED FIGURES ARE:
ACTUAL
IN THOUSANDS
IN MILLIONS
U.S. DOLLARS
FOREIGN CURRENCY (Specify)
21. BALANCE SHEET AS OF (Month, Day, Year) 22. FISCAL YEAR ENDS (Month, Day, Year)
23. PREPARED STMTS.
YES
ARE ATTACHED
24. ASSETS 25. LIABILITIES AND NET WORTH
A. Current Assets A. Current Liabilities
Cash
Short Term cash investments
Accounts receivable, less allowance for
doubtful accounts of $
Inventories
Other current assets (Itemize below)
Total Current Assets
B. Property, Plant and Equipment
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
B. Other Liabilities
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
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
26. FROM (Month, Day, Year) 27. TO (Month, Day, Year)
A. Net Sales
28. INCOME
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)
ZIP CODE
Yes No
Yes No
A.
B.
C.
CITY STATE ZIP CODE
Yes No
Yes No
AREA CODE NUMBER
AREA CODE NUMBER EXT.
AREA CODE NUMBER
STREET ADDRESS
37. Maximum Amount
Authorized ($)
38. Amount
Outstanding ($)
39. Loans Secured by Company's Assets - Real and Personal Property
BANK 1 BANK 2
SECTION V - BANKING AND FINANCE COMPANY INFORMATION
(Please attach a separate sheet using this format for any additional banks.)
ITEM
29. Name of Bank
30. Contact Person
31. Phone Number
32. Fax Number
33. Address
34. Amount Owing ($)
35. Term Loans
36. Line of Credit
D.
SECURED PARTY NAME CONTACT NAME
STREET ADDRESS CITY STATE ZIP CODE
SECURING ASSETS MATURITY DATE MONTHLY PAYMENT ($)
SECURED PARTY NAME CONTACT NAME
STREET ADDRESS CITY STATE ZIP CODE
SECURING ASSETS MATURITY DATE MONTHLY PAYMENT ($)
SECURED PARTY NAME CONTACT NAME
STREET ADDRESS CITY STATE ZIP CODE
SECURING ASSETS MATURITY DATE MONTHLY PAYMENT ($)
SECURED PARTY NAME CONTACT NAME
STREET ADDRESS CITY STATE ZIP CODE
SECURING ASSETS MATURITY DATE MONTHLY PAYMENT ($)
40. ARE ANY OF THE ASSETS SHOWN ON THE BALANCE SHEET
PLEDGED OR MORTGAGED, EXCEPT AS STATED ABOVE?
41B. TOTAL
LIABILITY ($)
41A. IF CONTRACTOR IS A PARTNERSHIP OR SOLE PROPIERTORSHIP, ARE
THE INDIVIDUAL LIABILITIES OF THE PROPIETOR(S) FOR FEDERAL
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 (Explain in Section VII, Remarks)
NO
YES (Provide detailed information in Section VII, Remarks)
GSA FORM 527 (REV. 3-99) PAGE 3
AREA CODE NUMBER EXT.
STREET ADDRESS
CITY STATE
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 ($)
ITEM 44. SUPPLIER 1 45. SUPPLIER 2
AREA CODE NUMBER EXT.
AREA CODE NUMBER
STREET ADDRESS
STATECITY ZIP CODE
ITEM 46. SUPPLIER 3 47. SUPPLIER 4
A. Name of Supplier
B. Contact Person
C. Telephone
D. Fax
E. Address
F. Amount Now
Owing ($)
G. High Credit ($)
A. Name of Supplier
B. Contact Person
C. Telephone
D. Fax
E. Address
F. Amount Now
Owing ($)
G. High Credit ($)
AREA CODE NUMBER EXT.
AREA CODE NUMBER
STREET ADDRESS
CITY STATE ZIP CODE
AREA CODE NUMBER EXT.
AREA CODE NUMBER
AREA CODE NUMBER EXT.
AREA CODE NUMBER
STREET ADDRESS
CITY STATE ZIP CODE
SECTION VII - CONSTRUCTION/SERVICE CONTRACTS INFORMATION (Public Buildings Service Contracts Only)
CONTRACTS IN FORCE
STREET ADDRESS
CITY STATE ZIP CODE
GSA FORM 527 (REV. 3-99) PAGE 4
ITEM 48. CONTRACT 1 49. CONTRACT 2
A. Location
B. Owner's Name
C. Address
D. Type of Work
E. Contract Amt. ($)
F. % Completed
G. Est. Comp. Date
STREET ADDRESS
CITY STATE ZIP CODE
STREET ADDRESS
CITY STATE ZIP CODE
ITEM
A. Location
B. Owner's Name
C. Address
D. Type of Work
E. Contract Amt. ($)
F. % Completed
G. Est. Comp. Date
50. CONTRACT 3 51. CONTRACT 4
STREET ADDRESS
CITY STATE ZIP CODECITY STATE ZIP CODE
STREET ADDRESS
GSA FORM 527 (REV. 3-99) PAGE 5
C. Address
D. Telephone
E. Type of Work
F. Contract Amt. ($)
G. Amount Sublet ($)
STREET ADDRESS
CITY STATE ZIP CODE
AREA CODE NUMBER EXT.
STREET ADDRESS
CITY STATE ZIP CODE
AREA CODE NUMBER EXT.
ITEM 58. JOB 3 59. JOB 4
A. Location
B. Contact's Name
C. Address
D. Telephone
E. Type of Work
F. Contract Amt. ($)
G. Amount Sublet ($)
STREET ADDRESS
CITY STATE ZIP CODE
AREA CODE NUMBER EXT.
STREET ADDRESS
CITY STATE ZIP CODE
AREA CODE NUMBER EXT.
ITEM 60. JOB 5 61. JOB 6
A. Location
B. Contact's Name
C. Address
D. Telephone
E. Type of Work
F. Contract Amt. ($)
G. Amount Sublet ($)
STREET ADDRESS
CITY STATE ZIP CODE
AREA CODE NUMBER EXT.
STREET ADDRESS
CITY STATE ZIP CODE
AREA CODE NUMBER EXT.
ITEM 52. CONTRACT 5 53. CONTRACT 6
A. Location
B. Owner's Name
C. Address
D. Type of Work
E. Contract Amt. ($)
F. % Completed
G. Est. Comp. Date
STREET ADDRESS
CITY STATE ZIP CODE
STREET ADDRESS
CITY STATE ZIP CODE
ITEM
A. Location
B. Owner's Name
C. Address
D. Type of Work
E. Contract Amt. ($)
F. % Completed
G. Est. Comp. Date
54. CONTRACT 7 55. CONTRACT 8
STREET ADDRESS
CITY STATE ZIP CODE
STREET ADDRESS
CITY STATE ZIP CODE
LARGEST JOBS YOU HAVE COMPLETED IN THE LAST FIVE YEARS
ITEM 56. JOB 1 57. JOB 2
A. Location
B. Contact's Name
CERTIFICATION
For the purpose of establishing financial responsibility with, or procuring credit from the General Services Administration, we furnish the above
as a true and correct statement of our financial condition and further certify that all other statements are true and correct. There has been no
material change in the applicant's financial condition since the date of the above statement. We agree to notify you immediately in writing of
any materially unfavorable change in our financial condition. In the absence of such notice or of a new and full financial statement, this is to be
considered as a continuing statement.
NAME OF BUSINESS
BY (Signature of Authorized Official)
NAME OF AUTHORIZED OFFICIAL (Type or print)
TITLE OF AUTHORIZED OFFICIAL (Type or print)
DATE
GSA FORM 527 (REV. 3-99) PAGE 6
NUMBER
STREET ADDRESS
CITY STATE ZIP CODE
AREA CODE NUMBER EXT.
AREA CODE NUMBER
STREET ADDRESS
CITY STATE ZIP CODE
64. PRESENT AMOUNT OF BONDING
COVERAGE ($)
65. HAS YOUR APPLICATION FOR SURETY
BOND EVER BEEN DECLINED? (If Yes,
please provide detailed information in Remarks)
66. DURING THE PAST 2 YEARS, HAVE YOU BEEN CHARGED WITH A
FAILURE TO MEET THE CLAIMS OF YOUR SUBCONTRACTORS OR
SUPPLIERS? (If Yes, 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).)
LIST COMPANIES FROM WHOM YOU OBTAIN SURETY BONDS
ITEM 62. SURETY COMPANY 1 63. SURETY COMPANY 2
A. Company Name
B. Contact's Name
C. Telephone
D. Fax
E. Address
AREA CODE NUMBER EXT.
AREA CODE
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GSA Form 527 - SIN 246-54 Only July 2015 C:PERFORMGSAG527.FRP

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Completed 3 March 2020

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