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

CONTRACTOR'S QUALIFICATIONS AND FINANCIAL INFORMATION

OMB Control Number: 3090-0007
Expiration Date: 9/30/2018

Paperwork Reduction Act Statement - This information collection meets the requirements of 44 USC § 3507, as amended by section 2 of the Paperwork Reduction Act of
1995. You do not need to answer these questions unless we display a valid Office of Management and Budget (OMB) control number. The OMB control number for this collection is
3090-0007. We estimate that it will take 2.5 hours to read the instructions, gather the facts, and answer the questions. Send only comments relating to our time estimate, including
suggestions for reducing this burden, or any other aspects of this collection of information to: General Services Administration, Regulatory Secretariat Division (M1V1CB), 1800 F
Street, NW, Washington, DC 20405.

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

5. STATE OF INCORPORATION

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

7. KIND OF PRODUCT OR SERVICE PROVIDED
10. INVENTORY VALUATION METHOD

8. FORMER BUSINESS NAME
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

PERCENT
BUSINESS OWNED

13. IF "YES" TO ANY QUESTION BELOW, PROVIDE DETAILED
INFORMATION IN SECTION VIII, REMARKS
A. HAVE YOU, OR ANY OF YOUR AFFILIATES EVER FILED FOR BANKRUPTCY?

12. PARENT COMPANY (If applicable)
A. NAME

YES

NO

B. DO YOU HAVE ANY JUDGMENTS, LIENS, OR PENDING SUITS?

B. CITY

C. STATE

C. DO YOU HAVE ANY CONTINGENT LIABILITIES?
D. HAVE YOU OR ANY OF YOUR AFFILIATES DISCUSSED BUSINESS OPERATIONS WITHOUT
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 527 (REV. 10/2015)

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 STATEMENTS

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 below)

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 below)

B. Other Liabilities
Mortgages
Bonds
Deferred income taxes
Other long term debt
Total Other Liabilities
Total Liabilities

Total Other Assets

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

D. TOTAL ASSETS

E. TOTAL LIABILITIES AND NET WORTH
SECTION IV - INCOME STATEMENT

26. FROM (Month, Day, Year)

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 below)

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 527 (REV. 10/2015) 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

EXTENSION AREA CODE

NUMBER

AREA CODE

NUMBER

AREA CODE

NUMBER

STREET ADDRESS

STREET ADDRESS

33. Address

CITY

EXTENSION

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 THE INDIVIDUAL LIABILITIES OF THE PROPIETOR(S) FOR
FEDERAL AND STATE INCOME AND/OR EXCESS PROFIT TAXES
INCLUDED ON THE BALANCE SHEET?
YES
NO

41B. TOTAL
LIABILITY ($)

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 527 (REV. 10/2015) 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

EXTENSION AREA CODE

NUMBER

AREA CODE

NUMBER

AREA CODE

NUMBER

STREET ADDRESS

E. Address

EXTENSION

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

EXTENSION AREA CODE

NUMBER

AREA CODE

NUMBER

AREA CODE

NUMBER

STREET ADDRESS

E. Address

CITY

EXTENSION

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 Amount ($)
F. Percent Completed
G. Estimated
Completion Date

ITEM

50. CONTRACT 3

51. CONTRACT 4

A. Location
B. Owner's Name
STREET ADDRESS

C. Address
D. Type of Work
E. Contract Amount ($)
F. Percent Completed
G. Estimated
Completion Date

CITY

STREET ADDRESS
STATE

ZIP CODE

CITY

STATE

ZIP CODE

GSA 527 (REV. 10/2015) 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 Amount ($)
F. Percent Completed
G. Estimated
Completion 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 Amount ($)
F. Percent Completed
G. Estimated
Completion 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

CITY

EXTENSION AREA CODE

STATE
NUMBER

ZIP CODE
EXTENSION

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

ITEM

58. JOB 3

59. JOB 4

A. Location
B. Contact's Name
STREET ADDRESS

STREET ADDRESS

C. Address

D. Telephone

CITY
AREA CODE

STATE

ZIP CODE

CITY

EXTENSION AREA CODE

NUMBER

STATE
NUMBER

ZIP CODE
EXTENSION

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

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

CITY

EXTENSION AREA CODE

STATE
NUMBER

ZIP CODE
EXTENSION

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

GSA 527 (REV. 10/2015) 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

EXTENSION AREA CODE

NUMBER

AREA CODE

NUMBER

AREA CODE

NUMBER

STREET ADDRESS

E. Address

STREET ADDRESS

CITY

64. PRESENT AMOUNT OF BONDING
COVERAGE ($)

EXTENSION

STATE

ZIP CODE

65. HAS YOUR APPLICATION FOR SURETY
BOND EVER BEEN DECLINED? (If Yes,
please provide detailed information in
Remarks)
YES

CITY

STATE

ZIP CODE

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)

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 527 (REV. 10/2015) PAGE 6