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Home My WebLink About20) Bid of Pace Contracting ~ I r'\ r-'\ I .i"~ Form No. 96 (Revised 19871 Filed , 19 Action taken B-102 P'e5C"Ml;l t1y seale Bl)ard IlI....c~Dllnll FOI'm No 961Re,,".e!5 \g,a71 A E. s.o,.c. Co.. In~. MUIl(:tlI. IN 12..1).... r\ CONTRACTORS BID FOR PUBLIC WORKS PART I (To be completed for all bids) (Please type or print) Date: /~ / a :;}./ lJ 5 1. Governmental Unit: c.r~o-t ~e~~~)hVI ilp-, 1M 2. County: C )0..,<" K 3. Bid:~:,::: }~J1~~n~:7/~ 4. Telephone Number: <& I ;;.. -~g:.; -572'1 _ 5. Agent of Bidder (if applicable): Pursuant to notices given, the underrigned offers to furnish labor and/or material necessary to complete the public works project of C.l~ 0+ Je.tt-e.rsOnllt Ir~~ern~ Unit) in accordance with plans and specifications of said unit for the sum of fff~-#~~ ~ $ II i.1 '1, OO'J . The under- signed further agrees to furnish a bond or certilied check with this bid for an amount speciried in the notice of the letting. If alternative bids appty, submit a proposal for each in accordance with the notice. If additional units of malerial included in the contract are needed, the cost of units must be the same as that shown in the original contract. If the bid is to be awarded on a unit basis, the itemization of units shall be shown on a separate attachment. The Contractor and his subcontractors, if any, shall not discriminate against or intimidate any employee, or applicant for employment, to be employed in the performance of this contract, with respect 10 any matter directly or indirectly related to employment because of race, religion, color, sex, national origin or ancestry. Breach of this covenant may be regarded as a material breach of the contract. ("': CERTIFICATION OF USE OF UNITED STATES STEEL PRODUCTS (If applicable) I, the undersigned bidder or agent as a contractor on a public works project, understand my statutory obliga- tion to use steel !3roducts made in the United S1'ates. I.C. 5-16-8-2. I hereby certify that I and all subcontractors employed by me for this project will use U.S. steel products on this project it awarded. I understand that violations hereunder may result in forfeiture of contractual payments. NON-COLLUSION AFFIDAVIT The undersigned bidder or agent, being duly sworn on oath, says that he has not, nor has any other member, representative, or agent ot the firm, company, corporation or partnership represented by him, entered inlo any combination, collusion or agreement with any person relative to the price to be bid by anyone at such letting nor to prevent any person from bidding nor to induce anyone to refrain from bidding, and that this bid is made without reference to any other bid and without any agreement, understanding or combination with any other person in reference to such bidding. He further says that no person or persons, firms, or corporation has, have or will receive directly or indirect- ly, any rebale, fee, gift, commission or Ihing of 'value on account of such sale. OATH AND AFFIRMATION I affirm under the penalties of perjury that the foregoing facts and information are true and correct to the best of my knowledge and belief. Dated at ", ~ ,\ f i'y\ this I ~ day of 7De~erY\ btt .11~fJ03 ~'J-J-c. By (N 01 Org , '2 Ii n · f./rlrn In I ~t';;,::O:S~ing) m~ r) and that the ACKNOWLEDGEMENT ss: being duly sworn, deposes and says that he is n of the abov13 I statements contained in the foregoing bid, certification, and affidavit are t~ and corre Subscribed and sworn to before me this /5? da of D _ My Comission Expires: ~ ru..<U" ~ J ~ OOt5 County of Residence: C. \c\..r \-t" '. \ B-103 v-~:~ ACCEPTANCE The above bid is accepted this following conditions: day of ,19_, subject to the Contracting Authority Members: PART II Governmental Bidder (Firm): Date: (Complete sections 1,11,111, and IV for all state and local public works projects as required by statutes.) U,it ~7~E';'s.~frf. 1# tal! . fuJ if\S I C. /:L!/g!03 These statements to be submitted under oath by each bidder with and as a part of his bid. Attach additional pages for each section as needed. SECTION I EXPERIENCE QUESTIONNAIRE 1, What public works projects has your organization completed? Conlract Amount Class of Work When Completed Name and Address 01 Owner r., 2. What public works projects has your organization now in process of conslruction? Contract Amount Class of Work When 10 be Completed Name and Address 01 Owner 3. Have you ever failed to complete a'r.j' work awardod to you? T\ II Wit If so, where and why? 4, List references from private firms for which you have performed work. S~;~ t\-t-tod\().A. . ~" fi"\ B-104 r. \...' , I SECTION II PLAN AND EQUIPMENT QUESTIONNAIRE 1. Explain your plan or layout for performing proposed work. 2. If you intend to sublet any portion of the work, state the name and address of each subcontractor, equip- ment to be used by the subcontractor, and whether you expect to require a bond. 3. What equipment do you intend to use 'for the proposed project? 4. Have you made contracts or received offers for all materials within prices used in preparing your proposal? SECTION III CONTRACTOR'S FINANCIAL STATEMENT Attachment of bidder's financial statement is mandatory. Any bid submilled without said financial stale- ment as required by statute shall thereby be r$ndered invalid. The financial statement provided hereunder to the governing body awarding the contract must be specific enough in detail so that said governing body can make - a proper determination of the bidder's capability for completing the project if awarded. SECTION IV OATH AND AFFIRMATION I hereby affirm under the penalties of perjury that the facts and information contained in the foregoing bid for public works are true and correct to the best of my knowledge and belief. Dated at ~.m this J~ daYOf~ t::.n By f'\ , ACKNOWLEDGEMENT STATE OF Ken-k.t~ COUNTY OF ~~en;0V) '---rD.' l0ocd. -f\t\~ \V\<< f(\~ - (Tille) ss: being duly sworn, deposes and says that he is of the above .:J001 &11\f.raC-tJ ry I L/....tland that the (Name 01 Organization) answers to the questions in the foregoing questionnaires and all statements t rein contain d are true and correct. Subscribed and sworn to before me this /'1, day of ee. ,;-h CJ.,c63 Jfwrtf 11b~ ' . I\lola ub ic . ~()tJ5 . My Commission Expires: Jeh rua..t J f I County of Residence: CJax k I J AI' B-105 r", r r TO THE BIDDER - The following Form 96a is not required by the State Board of Accounts. However, the bidder must either use this form or one similar ~o it prepared by their accountant. JACOBI, TOOMBS AND LANZ, INC. C: \SyJney\wl1Jocs\llliscellnIlCClltS\molslcr\divB. ~l)J B-106 o " 0, f'! STANDARD QUESTIONNAIRES AND FINANCIAL STATEMENT FOR BIDDERS Prescribed by THE STATE BOARD OF ACCOUNTS OF INDIANA General Form No. 96~a Prescribed by the State Board of Accounts of Indiana. Revised 1949 For use in investigating and determining the qualifications of bidders on public construction when the aggregate cost of any such work or improvement will be Five Thousand Dollars or more. These statements to be submitted under oath by each bidder with and as a part of his bid, as provided by Chapter 305, page 1248, Acts of 1947. ..........u.................................................................................................................. ........................................--......................................................................... ..................................................................................................................... .................................................................................................................. A.E. BOYCE, MUNCIE, IND c: \Sydl1 ~'\'lVpd(lcs\miscell.:1I1\;.'Qus\ll1..sle1"\JjvB. 'lVpJ B-107 uc . Submi'tted by......b:.....Ccn~aI::i!..f!j.J..IJ!3.............................................................................................. { ~ ~~~:a~~~~~ip , An Individual Principal Office at ......~().()......JD[Ut.!.14.er....Ln.................................................................................................................................................. r\ i ..................................sJ.e~LHII..e:........IIJ/...:~11!...34..............................................................................................................n EXPERIENCE QUESTIONNAIRE The signatory of this questionnaire guarantees the truth and accuracy of all statements and of all answers to interrogatories hereinafter made. 1. How many rears has your organization been in business as a general contractor under your present business name? . ;:?.\.f1 c..e..... ... .~q .1...... ... ....... ... ... ..... ...... ...... ......... ......... ........ .... ... ......... ..................... ................... ...... ............ ................ ....................... .......... ..... ........ How many years experience in construction w6rk has your organization had (a) as a general contractor; and (b) as a subco ntracto r? .....;?.l.K....... ...... ................ ........ ........... .... ......... "';;'''T~ .;..;:...i;:...:.....J'.....:.......... ...................... n..... ...........n....................... n'" What projects has your organization completed?..qee....u:t:;:!:;ULL.~....Li.stn.n.................................................n.......n.... 2. 3. CONTRACT AMOUNT CLASS OF WORK WHEN COMPLETED NAME AND ADDRESS OF OWNER ,.......................................-...................... ....... .0_... ................ .0... 0_... 0_.. ......~. ........... ................................................................. .........................-..--.--.-............................ ............................................................... ............................................................... .............................................................. ..................................................---.......... What projects does your organization now have in process of construction? C0NTRACT AMOUNT CLASS OF WORK WHEN COMPLETED NAME AND ADDRESS OF OWNER ......$.~.e......<illo.chedL.. ..l...\..&................................,........... .............................................-................... ................................................................ ............................................................... ................................................................ ......................................-........................ ................................................................ 4. Have you ever failed to complete any work awarded to you? If so, where and why. .....Q~..t.........NI.~..............................................................,.......................................................................................................................................... ..........................................................................................................j_......................................-.............................................................---................................-...... . ..... ............. ............ .... .... .... .... ......... ....... .... ................ .... ...... ....... ... .~... ............... ... ..... ....... .... .................. ... ......... ....... ..... ...... ................... ............. ..... ........ .....~.... 5. Has any officer or partner of your organization ever been an officer or partner of some other organization that failed to cotl~te a construction contract? If so, state name of individual, other organization and reason therefor. ... ..~D"" ...............'I.t:........... ......... ........................ .................. ....,.......... ....... .............. .... ......................... ............. .......... .................. ....................... .............. 6. H~~..~~y.;ffi~~;.;.;.p.~~.~~.;.;"f".y~~;.;~g~~i.~~ti~~.~~~;.f~i"i~d.t;..~;.~p.i~t~..~.~~~~~;;~ti.~~..~;.~t~~.~~..h~~di~d .i~.hi~jh~; own name? If so, state name of individual, name of owner and reason therefor. . ...... Nf!:>... f' ..... ...N./.fl:....... ........ ................ ...... .................. ....,........... .... ...... ............... ......... .......................... .............................. ..................... ................ 1~.;i~~t.~th~;..ii~~.~..;"{.b~~i.~~.~~..~;~.y~~.fi~~~~.i~i"iy.i~t~.;~~.t~d.?..................................................................................... .................. ....... ................jV'..Q.N.6"..................................................................,.......................................................................................................................................... .........................................................................................-........-................................................................-............................................................-......................... , c: \S)'dne~'\f\1'JClcs\m iscellilllenus\ll1.:lsler\Jjv B. wpJ B-I08 ,8. For what corporations or individuals have you performed work, and to whom do you refer? .........see..a-l:::/:;.actd....6.~........................................................................................................................................---............................ ......................................................................................................1........................................................................................................................................c... .......................................................................................................,................................................................................................................................................ r----.. r I . ,.....................................................................................................1............................................................................................................................................ -9. ......................................................................................................t............................................................................................................................................ For what cities have you performed work and to whom do you refer? ..........:::See.....ai;t;a~....6st:.....................................................................................;.........................................................--.............. ........................................................................................,................j......................................................................0........................................................................ ..................................................................-............................................................................................................................................................................................ ...............................................................................................................j......................................................................................................................................................... ................................................................................................................................................................................................................................................................................................... 10. For what counties have you performed work and to whom do you refer? ......we..e....{)j;-fu..d-:J.ed........L:I~...........................m................................................................................................................................... ................................................................................................................................j............................................................................................................................................................... ......................................................................................................r............................................................................................................................................ .........................................................................................................,................................................................................................................................................................ 11. F~;.-;.h~t..S~~~~..b~;~~~~..~.;..d~p.~;t~~;~~..h~~~ .y~.~..p~;f;.;.~~d.~~;k.~~X~~.-;h~~..d;..y~~..~.~.f~.;?... ..... ....................... ......... ..se.f:.:......a:t::-t:.4.Cbed.....Ll..SI':..................................................................................................................................................................... .................................................................................................................................................................................................................................................................................................................. I . '. ............................................................................................................................................................................................................................................................................................',.... , ................................................................................................................................................................................................................................................................................. 12. H~~~.y~.~..~~;i~.p~;f~~~~:i'.~~y..;~.;k.f~.;..th~..U~r.G~.~~.;~.~~;~?...If"~;:..;.h~~..~;d'~~.;h~.~..d~.y~~.;~f~;.?................... ............._~.).......N/fl::.........m..n....m.....................n............................................................................................................................................ ........................... .... ..... .............................. ............. ................ ............................. ..,j,. ..................................... .............................. ............................................................................. ~....... , ............................................................~................................................................................................................................................................................................................... ......................................................................................................................................................................................-............................................................................... ............................................................................................................................................................................................................................................................................... 13. What is the construction ex erience of the rinci al individuals of our or anization? PRESENT YEARS OF POSITION OR CONSTRUCTION MAGNITUDE AND OFFICE EXPERIENCE TYPE OF WORK . .5.. ~g.....~.............. ........ ................... ................. ............. .......... ....... ......... ................. ...... ...... ......................... ............. ..... .... ............. ....................---..... ..... INDIVIDUALS NAME IN WHAT CAP ACITY .............. ..... .... ................. ............. .. ................ .................. ................ .. ......... .................. ........... ......... ... .. ........ ................... .... ...... ....... ..... . ..~.............. ... ..-....... ....... ..........; .... ..................................................... ................................................... ..................................................... .....n............................................... ................................................... .................................................... ..................................................... .......................................................... .................................................... ..........n...................................... .... ............... .... ................ ............. .............. ........ .............. ...... .............. .... ................. ...~.. ....... .......... ........... ................... ............ ...... ................ .... ........ .................. .... ......... ......... .................................................n. ......n........................................... ..................................................... ..................................................... ....................................................... . ............... ........ ...... ... .......... .......... ................. ... ....... .......... ........ ..... ........................................ .... ........ . ............ .......... ..... ............ ........ ...... .................... .....~.... ..... ...... ..........n. .................................................. ................................................... ........................................................ .......................................................... .................................................. (\ ............... ........... ~............;,. .................................... .......... ......... . .........;............ ............................... ........................ ....... ........ ........... .. .. ................................................. C: \Sydney\wpdl1cs\miscl.:lbncous\m .1sler\div B. wpJ B-109 PLAN AND EQUIPMENT QUESTIONNAIRE The signatory of this questionnaire guarantees the truth and accuracy of all statements and of all answers cc interrogatories hereinafter made. r, .L. In what manner have you inspected this proposed work? Explain in detail. .........$~.+e.......J.).!.~.l.t.....................................................,.......................................................................................................................................~.... ......................................................................................................................................................................................................................................................................................... ...........................................................................................................................................................................u............................................................-.......................................................P- .......0......................................................................................................~...................e........................................................e...........u................................................... ......................................................................................................~.......................................................H.........,......................................................................... 2. Explain your plan or layout for performing the proposed work. ...........p.e,r.....p}~S.......(J...~....SpeCl.~\.CCU~!...~.t!.S.................................................................................................................... .........................................................................................e....................................................e.................................................e.............................................................. ..............................................................................................e.................................................................................................................................................................. ...................................................................................................................................................................................................................................................................... ...............................................................................................................'"...........................................................................................................................................................................--.. .....................................................................................................................................................................................................................................................................................................-............ ...................................................................._....................................................,...................................................e............................................................................................................................... ...............................................................................................................................:.......................................................................................................................................................................................... ........................................................................................................................................................................................................................................................................................................ ............................................................................................................................................................................................................................................................................................... ..................................................................................................................................................................................................................................................................................................... ........................................................................................................................................................................................................................................................................................................... ............................................................................................................................................................................................................................................................................................................... Th~.;~;k:..if.~;;~.d~.d..~.~..y~~:..;ili..h;;~..~h~..p~;~~.~;i..~~p~;~i~i;.;..~.f".;h.;~?................................................................................. .....................................................................~..I..Qm....0.-9.;?!1....................................................................................................................................... 4. .,:.....D~.y~~.i;;.~~.~.d..~~."d~.~h~.I;~;~.ii";;..g .~~.~h~..p;.~p~;~~{";~;k.;i.~.h..y.;~..~;~..f~;~~~.?..if".~.;.:.gi;~.~~;.~~~.~.;;.d..~yp~..~f equipment to be used. ......................................................~~?~.......~.tTh....~.~~ffi.l1w~.:::...~~A:'::ifL...~~.::...5.~......... ..........................................!t:....Bi~1.....~.~~~...:.T.P......f..~.......................................................................................................................... 5. ':. If you intend to sublet the hauling or perform it through an agent, state amount of subcontract or agent contract and, if known, the name and address of subcontractor or agent, amount and type of his equipment, and financial responsibility. ......................................................................................................... ..................~........................................................................................................... .............. ............... ......... ... ........... .........................................................e....................................................................................................................................................................................................................................... ...............................................................................................................................'........................................................................e...................................................................................... . . 6. .,:.....D~.y~~.i.;;.~~~d.~~.d~.~h~..g;~di~g.~~.~h~.p ;~p.;~~X.;;.~k..;i~h.y~.~.;.;;~.f;.~.~~~.?.................. ................................................ ... ..... ...... ..... ..... ..... ..... ......... '::1-~~........... ..... ........ ... ... ............. ... ...... ... ....... ....... ... ............ ...... ......... ... ..... ........... ..... .... .......... .... ..... ............... .... ......... ....... ...... ..............................................e..............................................................................,.......................................................................................................................................................................... ......................... .... ........... .................... ....... ..... ................................. .... .... ............ ......... ......~..... .............. ............ ........... ... .......... ............... ........ ..... .......... ......... ....... ................. .......... ....... .... .........-.. .. ................. ..... ..... ................................ ...... ........ .... ....................... ........ ........ .......... .....~ .... .... ............ ........ .............. ........ .............. ...... ...... .......... ............. ......... ..................... ....... ......... ........ ;;.... i;~.~~;.4: '5:' 6.~~d7.;,;~y.~~~.b~.;pp.li~~bi~.;~.;ii.b~i.ldi~.g.~~.~~~';~;~:'"ii ~;;;:~;:;;i;:""" ........... ....... ........... .......... .............................. .......... ........ ........... ....... ...... ............... ..... r, C :\8yJneY\'I\'Pdocs\m lscl::!lnnellus\l1l asler\JivB. wpJ B-110 . 7. ':-. If you intend to sublet the grading or perform it through an agent, state amount of subcontract or agent'~ contract and, if known, the name and address of subcontractor or agent, amount and type of his equipment and financial responsibility. 0, i ::::::::::::::::::::::::::::::::Q;?g:::~~~~::~:~:::::jfu{:::::?;;.~:~~:::::~:~~::::9:~:~~::::Pri?f.:0.t::::::::::::::::::::::::::::: .....4.......................................................................................................;...........................................................................................................--...................................-........ 8. D .~..y.~~..i;~~;d..~~..~~bi~.~..~~y.~a;:~;.p~;;i~~~.~f:~h~.;:~~k?...if.;~.:.~~~~~..~~~~~~..;T~~.b~~~~~~~~..~~;..~{.in~~;;:~~..~h~ name and address of the subcontractor, amount and type of his equipment and financial responsibility. ::::::::::::::::~~::::i?Avi:~:::~:::::::""h?:~l:~~;~:ei~~:~::G::.:::::::::~=::::::ii..i~9.~:QQ9:::::~::::::::::::::::::::::::::::::::::::::::::::::::. .................................................................................................................................................................................................................................................................................... , 9 . F~~~..:;;;hi~h..~~b~~~~;~~~;.;~..~;.~g~~~~..~:i"~..y;~..~kp~~~..~~..;~q~i~~..~.b~.~.d?........................................................................................ .......................................................................................N.~,..................n........................................................................................................................ .............................................................................................................:................................................................................................................................................................. ................... .... ........................ ............. ...... ................. ........... ....... ~....... .:.................... .............. ~. ~........... ........... ..................... ................ ............... ............................... .. .... ................................................................................................................:........................................................................................................................................................ ro osed work? 10. QUANTITY ITEM CONDITION YEARS OF SERVICE PRESENT LOCATION ......................................................................................... ..................................................... ..................................................... .............................................. ............................................. .................................................................................. ............................................... .................................................... .............................................. ............................................. ................................................................................. ............................................... ........................................... .............................................. ............................................. .........:.................................... .......................--.............. ................................................ ............................................. ........................................... ........................................... .......................................... .......................................... .............................................. ............................................. ............................................. ............................................. .................................................................................. ............................................... .......................................... .......................................... ...............................--........... ........................................... ....................................... ............................................... .......................................... ............................................ ..--........................................... .......................................... ......__............................... .......w__.__.................................. ......................................n. ................................................ ............................................. .......................................... ....................................... ............................................... ..--.........................-.............. ......................................... .............................................. .......................................... .......................................... ................................................ ......................................-... .......................................... ............................................ ........................................... .......................................... ................................................ ........................................... ...............u...............w......... ......~.........................--........... ............................................. ......................................... ................................................ ............................................. ........................................... ............................................. r\ c: \Sydllc}'\wpdm.:s\misc:ellnnc:o\.ts\m.1Sler\divB. wpJ B-111 11 What eqmpment do you mtend to purchase for use on the proposed work, should the contract be awarded to you? APPROXIMATE COST QUANTITY ITEM DESCRIPTION, SIZE CAPACITY, ETC. (\ ................................. ............................................. ...................................................................................................................................... .......................................... ................................ ......................................... ..........................~9~~................................................................................ .................................. ....... .........................................- .......................................... ...........................................................................................................................-............... .......................................... .......................................... ........................................-.... ............................~.......................................................................-....-........-........-... ............-............................. . ...... .... .., .... ............ ..... ....... ........ ....... ......... ............ .-... .... .......... ...............~.................... ........................ .......... .......... ..................... ...... ............ .... ................... .... ........ ...-... ...........-................................. ............................................. ..................................-...................................................................................................... .......................-.............--.. ............-.............................. ............................................... ...................................................................................................................................... .......................................... 12.. How and when will you pay for the equipment purchased? ....................................................................................................................................................................................................................................................... , ................................................................................................................................................................................................................................................................... 13. Do you propose to rent any equipment tor this work? If so, state type, quantity and reasons for renting. .......................................N9..I.........~.fS..::...~jjg.':!VJ.....~...~r.t:.!i:Q~'E~...~...~~.~..T.>>L~:.................. ::::::::::::::::::::::::::::::::::::::::[i!.ii:::~::::Biii::::ii::::~:W~ii.{:::::~:::A:::::~~:::::::::::::::::::::::::::::::::::::::::::::::::::::::::: 14. H~~~..y~~..~~d~..~~.~~~~~t~..~.~..;~~~.i:;~d.fi;~..6.ff~;~.f~;.~lf.~~~~~i~i"~\~;i~hi;..p.~.i~~~.~~~d.i~.p~~p~~i;;g'y~~;'p~~p'~'~~'i? Do not give names of dealers or manufacturers. !.:::~:::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: I Dated at........h.1Lp..~.t?)..............................this .......!8....................................day of .~~................................. 20....~~........ .......M~.... By................... .................. ..... ... .. ................................................................... ...JimII1Ldrafl..f(c::.:.....l!1t!:.~....................................... (Title of Person Signing) 5T ATE OF tiell.:itJeJ?jm j 55: COUNTY OF....JtH~.Q::).........) ..~:..../1...loocL,...........................................m.................................being duly sworn, deposes and says that he is a member of -;ra&..~ebl1t1j.f.LC:............................................:.............and that the answers to the question..s in the foregoing <f (Name of Organization) '. '.".' . quest:~~:~i:~:~~~::;e~~:s t~~:~i~~jl:~~t:2~:;~d ofor~mmmm20P?m OmnuSSlOU expIres v:-ebrLtar.!fj"li0.czj~m+ .'.~ 1JZ. 8d/IuJ~ - B-112 C :\Sydney\'...pdClcs\m iscelli:lllcCl\.\s\m tlsLcr\di"B. wpJ CONTRACTOR'S FINANCIAL STATEMENT J ^,-LC Submitted bY~~c.bJ1!11d.LC:.......mm.m..m{ ~ g:~::~~~iF r:. principal office atJ.iMmf1)df.1.np.,tb(I<J~Jkr.${!!JJJtI/e,./LY7.&2.mm~I~~=ld~~ To .......................................................;).f~....iiiift.ehi4....~~a};C;al......2JY:CJ~...................................................... Conditions at close of business 1 2 ASSETS ' Cash: (a) on hand .L...........................{b) In bank L.......................................{c) elsewhere L....................... Notes receivable (a) due within 90 days .........._.............................................................................................. (b) due after 90 days .............................................. ............................................................. (c) past due .. ............. ............... ...... .... ..... ......... ... ..... ................. ....................... ..... ........ ... ....... Accounts receivable from completed contracts, exclusive of claims not approved for payment.............. Sums earned on uncompleted contracts as shown by engineer's or architect's estimate (a) Amount receivable after deducting retainage .................................................... (b) Retainage to date, due upon completion of contracts ............................................... Accounts receivable from sources other than constructl.on contracts Deposits for bids or other guarantees (a) Rec~verable within 90.d~y~...::::::::::::::::::::::::::::::::::::: (b) Recoverable after 90 days ..................................... Interest accrued on loans, securities, etc. .......................................................................................................... Real Estate: (a) Used for business purposes................................................................................................ (b) Not used for business purposes ..................................................................................... Stocks and bonds: (a) Listed - present market value ......................................................................... (b) Unlisted. present value ......................................................................... Materials in stock not included in Item 4 (a) for uncompleted contracts (present value) .............. (b) other materials (present value) ........................... Equipment, book value................ ................................ .... .... ..~... ....... ............. ............. ............. ...._...... ......... ....... ..... Furniture and fixtures book value ' , .....................................;...................................................................................... Other assets ... ........... ....... ....... .......... ...... ..... ....... .......... ............... ........ ... ........................................ ..T.~~;;j.A~~~~~. LIABILITIES Notes payable (a) to banks regular ........................................................................................................... (b) to banks for certified checks ..................................................................................... (c) to others for equipment obligations ......................................................................... (d) to others exclusive of equipment obligations............................................................... Accounts payable (a) Not past due ............................................................................................................... (b) Past due ..................................................................................................................... Real estate encumbrances _0'" ....... ... ....... .......0 "__0_'_" ...0_ ..... ..,.... .._.. ... ........_.......... ....... ...... ........ _0_..... -.....~. ........ -. ..... Other liab ilities ........ .......................... ........... ...m.......... .......... ......... ................. ........... ................... ................. ..... Reserves ..... ............ ..................................... ..... ................ ......,.... .......... .......... ........... ...... ................. ......... .......... ..... Capital stock paid up (a) Common.......................................................................................................... (b) Common ........................................................................................................... (c) Preferred .... ......... ..... ........... ............ .......................................... ................... ..... (d) Preferred ....... ........... ............................. ............................ ........... ..................... S urp I us (net wo rth) ............. ................ .................................... ................................................................................... , Total Liabilities CONTINGENT LIABILITIES Liability on notes receivable, discounted or sold..................................................m........................................... Liability on accounts receivable, pledged, assigned or sold ......................................................................... Liab ility as bondsman ...... ... ...... ........ ........... ............. ...... ... ........... .............. .... ............. ........... ...... ........... ......... ...... Liability as guarantor on contracts or on accounts of others ......................................................................... Other co n tingen t liab ilities . ............ ....... ...... ......... ..... .... .... ............... ............ .... ..................... ...... .......... ........... ...... Total Contine:ent Liabilities 3 4 5 6 7 8 9 10 12 13 1 2 3 4 5 6 7 1 2 3 C :\S)'Jney\t\1ldocs\miscellanc('IUS\I11<1slcr\div B.wpJ B-l13 Dollars Cts. -- 1 Cash DETAILS RELATIVE TO ASSETS (a) on hand .... .......... ....... ........ ........ ..~......................... ..... ..................... ............ ........ ............. $ .......... ................ .................. ...... (b) deposited III banks named below........................................................................ $ .................................................. (c) elsewhere - (state where) ......................................................................................... $ .................................................. r NAME OF BANK LOCA nON DEPOSIT IN NAME AMOUNT ..............................................................- .................................................................... ........................................................................ .....-..................................................................... ...................................................................... ...........................................................,................ ....................................................................-.. ..............................................................-........ ... ._,.. .....~... .~~.. .._. ..... .... __~... ......~. ..~........... .......~...~.. ~~~.~. ~._ ......... u~.~.. ~..~. ~........ ~.... ~.... ~~ ~ ~... ....~. ......~.... ...~....~..........~........ ~.~...~~~....~ ~.... ...... -....... ....~.. ... .................~~....... ....................... 2" . ,,~ (a) due within 90 days ................................................................................... $ .................................................. Notes receivable (b) due after 90 days ......_.................................................................................. $ .................................................. (c) past due ............................................................................................................. $ ................................................... FOR DATE OF MATURITY WHAT HOW SECURED AMOUNT RECEIVABLES FROM: NAME AND ADDRESS .... ~.... -... ~........ .. ~ ~ ~..... ~ ~............ ~ ............ ~........... ~.. ~....... ~.. ....... -............~.~....... ~.... ~ ~ ~.- ~.. ..... .... ~........ ~......... ................. ~........ -.................. ~................. ......... -. .... ~......~..... ~.... .... ~.... ~. ~. ~..... . ~. ~.~.~..-~............. .~.. ~..~.~....~......................~.~............ .................... ... ~ ................... ..:.~~ .. ~~.......~..~~.........~.. .....~.~~.~~.. .......~....~....... .~....... .... ~..... ......... ~.~~.. .~~...~~.. ...~...~....................... ... .- ............ .... ................~... ~.~...~.. ~...........~....~ ..~~........~.~.~~ ~.........~. ..... ... ...........~. ~.. .. ................. ~.~.... .....~....... ......~.....~....... _.~~.~. ..-.. ~.......~. ...... ~...... ..~......... ............~............ ~ ~ .~. Have any of the above discounted or sold? If so, st~te amount, to whom, and reason. .............. .......~... ~...... ~................. .... ~..~ ~................... ~......~. ~... ..~..... ~................... ~........ .......... ~................... ............... ~..... .................................... -.....................-................. -.... 3 " .,. Accounts receivable from completed exclusive of claims approved for contracts not payment.............................. ME AND ADDRESS OF OWNER NATURE OF AMOUNT OF AMOUNT RECEIV ABLE CONTRACT CONTRACT ............. ~ ..... ...... ...~.........~... ......... ~..... ........ ... .... ........... .... ..~ ............ .. ~. ..... ....~.... ~. ~ ~.. ~.......... ~.. .................... .... -............. ......... ~..- ... ~...... ~....... .... .~... ~.................~........ .... - --....... ........~.. ....... ........ ~ .~. ... ... .~. ~................. ................ ........-... ... ~~. .............. ~....... ....... ~............ ~... ~ ...... ~..".."'...".'..'''.''.'....... -........ ... ....... .......... .... .....~ ~.... ...... .......~u..... _. ...... ... ......... ...... ..... ............. .....~.. ...~...~..... .~.......~.......................... ~.... ~ ~. -.. -....... ~. ~......... -................ .........~....... ........... .... ....... ......... ............... -..... ~.".'...' ~.. _................-.............. ... ........ .... ..................................... ..~ ... ........~~ ......... ..~~. .....- .. ~......... ~. ~.................. ~.... ........ ..... ...... ~..... ... ~..""..."...... ~........... .......................... ~ ~.. ~....... ~.......... ~.................. Have any of the above discounted or sold? If so, state amount, to whom, and reason. .........~...... ~ ~.. ~ ~... ~.... ~. ~................... ~...... ~....... ~.. ~ ~.. ~..... ~................... ~...... ..... .;...... ~..... ............ ~....... ~... ~ ~... .... .....~. .... ......... ...... -. ~.................~. ~... ..~... -....... ~. -............ ~~...... ~...... Sums earned on uncompleted contracts, as shown by engineer's or architect's estImate 4 ". (a) Amount receivable after deducting $ ., retaInage........................... ................................... ... .......... ...~~.~..... ~...~......... n. .._.... _. (b) Retainage to date due upon completion of contract................................................ $ ............. ~. ~......... ~.... ~............ ~....... DESIGNA TION OF AMOUNT OF AMOUNT AMOUNT RETAINAGE AMOUNT CONTRACT AND NAME EXCLUSIVE OF AND ADDRESS OF OWNER CONTRACT EARNED RECEIVED WHEN DUE AMOUNT RET AINAGE ..... .~. ~... ... ~.'''''''''. .... ......... ............~.. ...... ... ~............... ~....... ~"."" .... ...........~..... ........ ................. ~.. ~............ ...... ~.................. -.. ......................... .....-.......................-...... ,.. ~.. ~. ............. ........... ~.................. ~. ......... ............ .... ~........ ~........ ............................. .... ........ ~..~.... ~...... ~.... .............- ......... ~..... ...................--.... .................................... ,~.................. ......... ~.......... .... ........ .... ..... ............. -- ~...... -........... ..-......................... ~. .............................. .......~......~........... .. ..............-.......... .. ~.. .u.~~... ....~... ... _.. ....... ..................................................~........u.. ................ ~. ~. ............... ............................ .................. ~............. ..........-................... ......... ~............. -. ... -..................... ~. . ..-..... Have any of the above been sold, assigned or pledged? If so, amount, to whom and reason. ............ ........... ...~ ...... ...... ......... .....u....................~. ..... ..... ................ .... ..j........ ..... ~.~. ... ......... .......~.... ..... .~............... ....... .... .~...... ..... ............ ~... ............~.~............. ~......... i .:parately each item amounting to 10 percent or more of the total and cqmbine the remainder. c: \S)'Jner\i\'ll,1(ll.:s\llliscclln11~("Ius\'ll.1slcr\Ji\'B. i\11J B-114 5 .r ~,. Accounts receivable from $ not constructIOn contracts ......................................................... ...............................................-........... RECEIV ABLES FROM: NAME AND FOR WHAT WHEN DUE AMOUNT ADDRESS - .......................................................................................................... ................................................. ................................................... ................................................ .... ..................................................................................................................... .................-........................................... .............................................................. ........................................................ ...................................................................................................................................... ................................................... .................................................. ................................................... What amount if any is past due ' . .................. $ ,....................................................... " .........................................................................!............................ r . 6 .r ". Deposits with bids otherwise $ or as guarantees ....................................................................... .............................................................. DEPOSITED WITH: NAME AND ADDRESS II FOR WHAT WHEN AMOUNT RECEIV ABLE ...........................................................-........................................................ .................................................... ................................................. ...................................................... ................................................................................................................. ..................................................... ................................................. .............................................. ............................................................................................................... ................................................. .................................................. ...-............................................ ...................................................................................................................... ................................................ .................................................. ............................................... 7 Interest accrued on loans, secuntles, etc. $ ................................................................................... ........................................................... ON WHAT ACCRUED TO BE PAID WHEN AMOUNT ............................................................................................................................................................. ............................................................ .................................................. .......................................................................................................................................................................... .............................................................. .................................................. ............................................................................................................................................................ .............................................................. .................................................... I ... ... ........ ....................................................................................... ..............~..............................._... .............-.................................................. ..................................................... 8 Real estate { (a) used for business purposes $ ,..............-..................................................... ......................................................... book value (b) not used for business purposes $ .......................................................... -........................................................ - IMPROVEMENTS TOTAL BOOK DESCRIPTION OF PROPERTY NA TURE OF BOOK VALUE VALUE IMPROVEMENTS 1 ..................-.............................................................................................. ..................................................... ......................................... ................................................. 2 ..............................-..................................................................................... ...................................................... ..................................... ................................................. 3 ...........................................-............................................................... .~................. ............. .............. .... .................................... ................................................ 4 ........................................................................................................ ................................................... ..................................... ............................................... 5 ................................................................................................................ ...................................................... ..................................... ............................................... 6 ............................................................................................................... ..................................................... .................................... ................................................ 7 LOCA TION HELD IN WHOSE ASSESSED AMOUNT OF NAME VALUE ENCUMBRANCES 1 ............................................................................................................... .................................................... .................................... .................................................. 2 ................................................................................................................ ........................................................ ........................................... ................................................. 3 ................................................................................................................ ...................................................... ...................................... .................................................. 4 ........................-............ .......................................'........ .............................................................................................................. ......................................................... 5 ........................................... ................................................ ............................................................................................................ ...................................................... , ............................................................................................................. .................................................... ...................................... ............................................... 7 'f List separately each it'em amounting to 10 percent or more of the total and combine the remainder. c: \8yJncY\"11Jocs\misc(.!llilnc~1us\1ll L1ster\div B. wpJ B-115 r DETAILS RELATIVE TO ASSETS (Continued) 9 Stocks and bonds (a) Listed - present market value $ 04............................................... ...................................................... (b) Unlisted - present value $ ........._...............................................e. ...-................................................... LIST NT. \ OR DIV. PRESENT ~ESCRIPTION ISSillNG COMPANY PAID PAR MARKET QUANTITY AMOUN1 VALUE VALUE DATE % 1 ...................................... ......................--................................................... ................................ ............................ ............................ ...................................-. .............................. 2 ......................................... .................................................................. ............................. .......................... ............................. ............................. ......................... 3 ...................................... .......................................................... ............................ .......................... ............................ ............................. .......................... 4 ............................................ ............................................................ .............................. ........................... ............................. ............................... ........................ 5 ...................................... .............................................................. .............................. ............................. ........................... .............................. ..................-...... 6 ....................................... ............................................................ .............................. .......................... ............................. ............................... ................................ 7 AMOUNT WHO HAS IF ANY ARE PLEDGED OR IN ESCROW, STATE FOR WHOM AND PLEDGED POSSESSION? REASON OR IN ESCRO\V 1 .......................................... ......................................................................................................................................................................................... ......................... 2 ,.......................................... ....................................................................................................................................................................................... ......................... 3 ........................................ ....... .............................. ....................... ~................................. .............................................. ................. ..................... .......................... 4 .......................................... ............................................................................................................................................................................................ .......................... 5 ........................................ .........................................................................................................................-...................................................................... ...........-.............' 6 ,......................................... . ... .. . . . . . . ... . . . . . . .. . .. . . ... .. . . . . . . . . ... . . . . . . . . . . . . .. . . . . .. . . . . .. .. .. . . .... . . . . . . . . . . . . ." . . . .. . .. . .. . .. .. . . . . . ....... .. ... . . ....... .... . . . . . . . . . . ~ ..... .. . . . . .. . . . . . ... . . . . . . . . . .... . . . . .. . . . .......................... \ Materials In stock and not included m Item 4, Assets: 1 0 (a) For use on uncompleted contracts (present value) $ ............................... ....................................................................... (b) Other materials (present value) $ ,.........................................-.......................... ................................................................... - PRESENT VALUE DESCRIPTION OF MA TERrAL QUANTITY FOR UNCOMPLETED OTHER MATERIALS CONTRACTS ........................................................................................ ............................................... ............................................................................ ................................................................... .........................................................-.............................. ............................................... .................................................................. ..................................................................... ......................................................................................... ................................................ ................................................................... ... ........... ...... ......... ......... ..~.. .... ......... .......... ....................................................................,;..................,;. ................................................. .................................................................. ................................................................ 1 1 .r ~.. Equipment book value $ at ...................................'................................................................................... ............................................................. QUANTITY DESCRIPTION AND CAPACITY OF AGE OF PURCHASE DEPRECIATION BOOK ITEMS ITEM PRICE CHARGED OFF VALUE ..-................................ .....................................................-.................................................... ....................... ........................................ .............................................. ..................... ................................ ............................................................................................................... ........................ .................................... ............................................ ......................... ................................. ............................................................................................................... ..................... ....................................... ............................................. ........................ r r there any liens against the above? If so, state total amount.......................................................... $ ........................................................ .or more items are lumped above, give the sum of their ages. c: \8yJI'eY\,(l!pJllCS\l11is<.::ellane~'u.s\I11<1sler\JivB. wpd B-116 12 13 DETAILS RELA rIVE TO ASSETS (Continued) Furniture and fi:h."tures at book value.......................................................m.m....................... $ Other assets $ ............................ ......... ....... ......... ....~. ... ..~........ ................. ................... .....-.................... ....... ........... ...... .........................................-...-... .... ..... DESCRIPTION AMOUNT .....................................................................................................................................................................................40................................................ ...................................................................... I Total Assets: DETAILS RELATIVE TO LIABILITIES (a) To banks, regular $ ................................................................................................................................ ................................................... 1 { (b) To banks for certified checks $ ................................................................................................ ......................................................... (c) To others for eqmpment o b Ii gati 0 ns. ............................................. ............... .... $ .................................................... (d) To others exclusive of eqmpment o b ligati 0 ns... ..m.... ................. ................. $ .................................................. TO WHOM: NAME AND ADDRESS WHAT SECURITY WHEN DUE AMOUNT ........................................................................................................ .................................................. .................................................... ................................................................. ...................................................................................................... ................1.............................. .................................................... .............................................................. I 2 { (a) Not past due $ ........................................................................................................................... ..................................................... (b) Past due $ .......-....................................................................................................................... ........................................................ TO WHOM: NAME AND ADDRESS FOR WHAT DATE PAYABLE AMOUNT ,................................................................................................. ................................................ .................................................. ................................................................. .......................................................................................... ..................................................... ................................................... ................................................................... 3 Real estate encumbrances (see Item 8, Assets) $ ................u................................................. .......................................................... 4 Other liabilities $ ......................................................................-............................................................... ............................................................. DESCRIPTION AMOUNT ................. ...... ........ .... ............ ...... ........ ....................... ...... ........ ..... .............~..................... ......... ..... ..... ............. ......... ... ...... ........ .............................................................. ....... ....... ..... u... ..................... .... ... .... ......... ....... ................................ ........... ..... ..... ............ .................4........ ........... ~..~............_ 4._.. ........... ..... ...~...... _.... ... ....... .......... ..... ........ ....... ........ 5 Reserves $ ... ...4.........................~. ........... ~.... ~...~................................................................ ........ ~......... ...~......... ~ .. .~........ ............. ....... .... ......... ..... .... .... INTEREST INSURANCE BLDGS & FIX PLANT DEPT. TAXES BAD DEBTS $ $ $ $ $ $ 6 { (a) Common $ Capital Stock paid ...........~........................ ..... 0........... .~...... .............. ........... ................ ..~..........~~................... ............... .... up (b) Preferred $ ...... ............. ................ ..... .... ........... ~...........~. ........ ............. ......... ....... ...................................................... 7 Surplus $ .... ~........... u.................................. ~.......................... ............. ......~.~....................,;........ ~ ..~.......................... 4...... ..... ..... .~.... ......... ..........~........... ........ .......... Total Liabilities: r\ c: \S)'tll1eY\I\'pJOCS\l11 iscdbncmlS\ll1ilSll!:r\Jiv B. ""lJ B-117 ,If a corporation, answer this: Amount fo r which incorpo rated ............................................................................................................................m............................................ ........... {\ I cal paid in cash ..... ....... ..m................ .......... ............................ ..................... ...... ........... ........... .................... $ ............................. ........ ................... ........ When inco rporated ..........................................................................................................................................._..................................................................... In what state ..................................................................................................................................................................................................................................... Names and titles of all persons having authority to execute and receipt estimate vouchers and to conduct other business for the corporation, including its officers, the signatl,l.res of whom are legally binding. ......................................................u............................................................................................................................................................................................................... .....................................................................-..............-........................................................................................................................................................................... ..................................................................................................................................................................................................................................................................-............ ................................................................................................................................................................................................................................................................................................. .... ........... .................. ...... ..... .... ............................................... .......... ......... ........ .... .... ~............ .... ... ...... .............. ......... ...................................... ..... .................................. ....... .... ... ........................... .-...... Do you have the necessary "certificate of authority" to transact corporate business in this state, under the terms of Chapter 215, Acts of 1929, and acts amendatory thereto? ............................................................................................................................... If ., co-partnership, answer this: r\. . f . Date of organization ......................................................m............................................................................ ........................... .............................................. . State whether co-partnership is general, limited or association ....................................................................................................................... Give the names, addresses and proportional interests of all parties............................................................................................................... NAME ADDRESS SHARE $ ....................................................................... ......................................................................................................................-. ............................................................ $ ...n...................................._............................. .......................................-............................................................................... .......................................................-..... $ .............................................................-...... ..........-....................................;..............................-....................................................... .....-...-.....................................................-...... ........-....................-.............................................................................................. $ ......-.........-..-........................................-... $ .........................................-...................... $ ......................................................-......... $ ..... -......... .......... ............... .................. ......... ....... .... ... ............................ ................... ...... .~.. ................. ........ ......................... ......... ........ ...................... ....... ........... ...... .............................. ........ ........ ............ ...... ........ ... ............ ........................................ ...................... ..................~.......... ...... ................ ........... ... ..... ~........ ...... ..... ............ .................... ..... ................ ... ............... .......... ....... ......... .......... ............. ... ....... .................................... ............................. ....... $ .. ............~................. ........... ............... ...~................. .....~ ........ .......... ......... ..... .... ........................... .... ......... C :\8ydnc)'\wpdocs\miscc!bneous\mi\ster\Jiv B. t\11d B-118 The name of the partnership firm under which the above partners are operating is......................................................................................................... Gi:;~.;;;~~;.~~.d '~i cl~~' ~f.;Jfp~~;~.~;.h;:;~g.~~~h~.;iry.~;-.~~~~::;~~.kd.;~~~ip~.~;~i~;~~~~.~~h~~~.~~d.~~.~~;d~~~..~~h~.;. b::;~i;;~~;.f~~.~h.~. p;~'~~~'~hip; the signatures of whom are legally binding. (' , .......................................................................................................'1........................................................................................................................................... ....................................................................................................................j..........................................................................................................................-..................-.............. Th~.;:;~d~~~ig;;~.d.h~~~by.d~~i~~~;..~h~~..~h~.f~~~g~.i~g.i;..~.~;;;~..~~.~~~.~~~~.~f. ~h~.ff~~~~i~i. ~~~di~i;-~.~f.~h~..i~di:;fd~~i:.~~~p~~.~~~~hip.~~.~~~p~~;~i~; herein first named, as of the date herein first given; that this statement is for the express purpose of inducing the party to whom it is submitted to award the submitter a contract; and that any depository, vendor or other agency herein named is hereby authorized to supply such party with any information necessary to verify this statement. NOTE: A co-partnership must give firm name and signature of all partners. A corporation must give full corporate name, signature of official and affix corporate seal. ...................................................................................-...................... ..............u...........~................................................................................................ ........ ....... .........~.................. ...... ........ ......................... ........ .......... ...... .............. .... .......... .................................................................................................................................. Afficlavit for Individual STATE OF ........................................................ ) ) SS: COlJN"TY OF ........................................................) .................................................................................................................,.........being duly sworn, deposes and says thereof that the foregoing financial statement, taken from his books, is a true and accurate statement of his financial condition as of the date thereof and that the answers to the foregoing interrogatories are true. .... ... ................. ......... .................... ........ ...... ........... ..-. .~.... (Applicant must sign here) Subscribed and sworn to me this...................................... day of ...,................... 20 ............... Notary Public Affidavit for Co-Partnership 'E OF ........................................................ ) ) S5: COlJN"TY OF ........................................................) ..................................................................................................................c........being duly sworn, deposes and says that he is a member of the firm of ..........................,................................................................................................and that he is familiar with the books of said firm showing its financial condition; that the foregoing financial statement, taken from the' books of said firm, is a true and accurate statement of the financial condition of said firm as of the date thereof and that the answers to the f9regoing interrogatories are true. ..............................................................................-........................ (Member of firm must sign here) Subscribed and sworn to me this......................................day of ......................20 ............... ..................................................................-....................................................................... Notary Public STATE OF ...t:(e.~...................J Affida,)it fOrCGrpofOcian- !J...c. COlJN"TY OF ......cJ.ette.r:~.......... ~ 55: .i.lQl.l1.....k.200.d......................................................................... bting duly ","om, '"'po"" md '"y' that ht i, a ffitffihrr of tht~C;::""" of .... .QLC-L..~a..cltf.1a..t.Lb...c..,......................................,described in and which executed the foregoing statement; that he is familiar with the books of said corpolatlOn showing its financial condition; that the foregoing financial state t, taken from the books of said corporation is a true and accurate statement of the financial condition of said corporation as of the d e the eof and hat th answer to the foregoing interrogatories are true...th"JC~j '-"-"'r;..'j;/ ? ' ....-~,.. ~'....~t1J;;~.........=~~~~~ik20()3....... c: \8>'dne}'\tvpdt,cs\l1liscclbnet'us\11l.:1sl~r\div B.I\'pd B-119