Bidder's Qualification Questionnaire

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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 ANDROLLING 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.

  1. 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
  2. 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:

  1. 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;
  2. 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;
  3. 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

  1. 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.
  2. 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.
  3. 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.

  1. 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.

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

    YES

    NO

     

  3. 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

     

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

    YES

    NO

     

  5. 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

     

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

    YES

    NO

     

  7. 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

     

  8. 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).

    _________________________
    _________________________
    _________________________
    _________________________

    _________________________________________________________
    _________________________________________________________
    _________________________________________________________
    _________________________________________________________

  9. 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:

  1. has or may have an impact on the Proposer's ability to perform any work called for by this solicitation; or
  2. 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
or Certification

Name of Holder

Issuing
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 VI - 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

 

 

$________

 

$________

 

$________


SECTION 1
(continued)
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 LIABILITY AND EQUITY

 

 

$________

 

$________

 

$________


DETAILS RELATIVE TO ASSETS

SCHEDULE A

Notes Receivable

(a) due within 90 days ___________$__________
(b) due after 90 days ___________$ __________
(c) past due __________________$ __________

 

Receivable From:
Name

 

Purpose

 

Date of
Maturity

 

How
Secured

 

Amount

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 


SCHEDULE B

Aging of Accounts Receivable

PAST DUE

 

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

 

$

 


Schedule J

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 STATEMENT OF CASH FLOW
STATEMENT FOR PERIODS 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 _____________________________)

 

 

) ss.:

 

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 _______________________
(Print title)

 

of _____________________________
(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)

 

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