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Home My WebLink AboutContractor's Financial Statement CONTRACTOR'S FINANCIAL STATEMENT Submitteci'by " /~ co N\ C~ I,..... cf:"'j LL,C r': : .... .............................. ......... ..... ............... ................. .1.. ...... ....... .... ...... ...... ...... ....... ............... ...... ..... A Corporation o par s '1 ~./ IJ Jf A1 L An Individual with rind al office at I' I d.- J., CP. '-'00 ttY . r'~""'I: oS :z ~ '171 '13 p p .........................................................................,/.................. ......... ./...................... ............ ... -......... ...... ............. .... 7ft .f.t,,. J...... 0;: tlJ .IN S () w V fie c<" ~ To ......-.....---.................................................................................................................................................................................................-.........................-................-..........................................................................-................................................................. ~/., j ~r\ Conditions at close of business 1 2 ASSETS Cash: (a) on hand l.........................<b) 1n bank t...................................(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 construction contracts ............................................. Deposits for bids or other guarantees (a) Recoverable within 90 days ................................ (b) Recoverable after 90 days ................................ Interest accrued on loans, securities, etc. ........._.................................................................................. Real Estate: (a) Used for business purposes................................................................................... (b) Not used for business purposes ......................................................................... (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 3 4 5 6 7 8 9 Stocks and bonds: 10 11 --...-...........-...........................................................................-.............................................................................. .......................................................................-........-..................-........--......................--............-............................................................................................................ Total Assets LIABILITIES 1 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 ...................................................... 2 Accounts payable (a) Not past due ................................................................................................. (b) Pas t due ...... ... ........ .... ........ .............. ....... ............ ... ... ........ ... ........ ..... ...... n' 3 Real estate encumbrances ...... ....... _... ......... ............. ................ ............ ................... ........ .................... 4 Other liabilities .......... ... _..................................................................................... ............. ................ 5 Reserves....................................... ................................................................................. ..................... 6 Capital stock paid up (a) Common ............................................................................................ (b) Common ........... .... ..... ....... ....... ... ...... ..... ............ .......... ... ........... ........ (c) Preferred ............ ............. ........ .......... ....... ................. ........ .... ....... ...... (d) Preferred . ...... ....... ...... ....... ....... .... ................. ........... ..... ............... ...... 7 Surplus (net worth) ............ .......... ............ ... .......... ................ ....... ........ ..... ................... ...... ............... ...... Total Liabilities CONTINGENT LIABILITIES 1 Liability on notes receivable, discounted or sold ................................................................................... 2 Liability on accounts receivable, pledged, assigned or sold ............................................................... 3 Liability as bondsman .. ............... ...... ..... ........ ....... .... .......... ....... ......... ...... .... ... ....... ......... ...... ....... ....... 4 Liability as guarantor on contracts or on accounts of others ............................................................... 5 ()ther contingent liabilities .... ......... .... ........... ................. .............. ...... ..... ...... ...... ....... ............ ....... ....... Total Continl!'ent Liabilities fc:e (l7l1J C(-Iff) S:\Sydney\WPDOCS\mlscellaneousIMASTER\divB.wpd B-115 Dollars Cts. j (a) on hand $ > r < ....................................................................................................................................................................................--................... .............................................................................. Cash (b) deposited in banks named below $ ................................................................................................................. .......................................................................... (c) elsewhere - (state where) $ ............................-.................................................................................................................. ..........................n............................................... NAME OF BANK LOCATION DEPOSIT IN NAME AMOUNT ......................................................................................................... ................-...........................................-........................................ .....................................................................-.................................. ........................................................................................ ............................-..................................................................-. .....................................-............................................................ .....................................-..-...........................................-............ .........................................................................-......-..-.......... ...................................................................................................... .............................................................................-...................... ........................................................................................................ ................................................................................................... (a) due within 90 days $ 2* ............................................................................................................................................ ......................-.......................................................... Notes receivable (b) due after 90 days $ ..........-........................................................................................................................................... ............................................................................ (c) past due $ ............................................_..._-.....-........................................................................-........................................... ..................................................................-.....-... RECEIVABLES FROM: NAME AND ADDRESS FOR WHAT DATE OF MATURITY AMOUNT HOW SECURED ..................................................................................................................................................................................................... .......................................... ............................................................................................. ........................................................................ ..................-........................................................--........................................................................................................... ............................................ ............................................................................................ ........................................................................ ........................................................................................................................................................................................ ......................................... ............................................................................................ ............................................................................. DETAILS RELATIVE TO ASSETS .~. ' "F' . Have any of the above discounted or sold? If so, state amount, to whom, and reason. -,...;Iti~'\ 3* I Accounts receivable from completed contracts exclusive of claims not appJ:Oved for payment .......................................... NAME AND ADDRESS OF OWNER NATURE OF AMOUNT OF AMOUNT RECEIVABLE CONTRACT CONTRACT .... ..... ...........~......... ............................................. ..................'............................................ ....................................................................... ......-......-............................................................ .....-............................................................................................... ............................--..............-....-..-.......--.-..----..-....-......._.._-..-.-.......................... ............................--.............-.--.--........... ......-........._............................................................. -......................................................................................................... ............................................................................................................................................... ....................-........................................................ ............................................................................... .......................................................................................................... ............................................................................................................................................. ........................................................................ ................-................................................................ ........................................................................................................... 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 $ ................................................................................. ..................................................................................................... (b) Retainage to date due upon completion of contract $ ................................................................................ .............................................................................. DESIGNATION OF A~f( lUNT OF AMOUNT AMOUNT RETAINAGE AMOUNT CONTRACT AND NAME EXCLUSIVE 01 AND ADDRESS OF OWNER C<lNTRACT EARNED RECEIVED WHEN DUE AMOUNT RETAINAGE ........................................-.......................................... .............-............................... ............................................. .................................................. ............................................ .......................................... .................................................... .................................--................................................ ........................................... ............................................. ................................................... ............................................... .......................................... ......-........................................... .............-.-................................................_......... .............-..--................. -..................................... ....-........................................ .........................................- .......................................... .................................................. ...................................................................................... .......................-.............. ... ....... .............. ..~............. ............. ..~.. ~....... .................. -.... ............................................... ....... .................. .........~..... ............................-....................... I-lavc any of the above been sold, assigncd or pledged? If so, amount, to whom and reason. . l.J!'1 ~cr:lt.ltcl}' each item amounting to 1 (I pcrct"nr or more of the total and combine the remainder. ~.~, S:\Sydney\WPDOCS\mlscenaneous\MASTERldlvB.wpd B-116 ~ 5* I Accounts receivable not from construction contracts $ ~........ .......... ............... ..... .............. .....-........ ........ ........ ........................................................................................... , CElv' ABLES FROM: NAME AND ADDRESS FOR WHAT WHEN DUE AMOUNT ............................................................................................................................................................................... .......................................................................... ......................................................................... .............................................................................. ..........-..-........................................................................................................................................................... .............._-........_-.................................-......... ................-................-................................... ...-............................-..--................................... .................................................................................~..................-..........................-.................................... .................................................-................. ........................................................................ ........................................................................ What amount, if any, is past due $ --" r 6* Deposits with bids or otherwise as guarantees $ ................................................................................................ .......................................................................... DEPOSITED WITH: NAME AND ADDRESS FOR WHAT WHEN AMOUNT RECEIVABLE ..................................................................................................................................................................................... .......................................................................... ..................................................................... ........................................................................ ............................................................................................................................................................................ .......................................................................... ......................................................................... ........................................................-......... ...-...........-...............................-..........................................................................................-....................--.. --..-....----...................-............................ -....--....-...--.........-.......--...-..-...-.---..- -..-....---............-..-........................................ ..................................................................................................................................................................... ................................................................... ....................................................................... ............................................................................ 7 Interest accrued on loans, securities, etc. $ .......................................................................................................................... ..............................................................-......................... ON WHAT ACCRUED TO BE PAID WHEN AMOUNT ....... .......... ...... ......... .........................~..................... ................................. ......................... ........ .................... .............. ............. ................................. ........ ....................................................................................... ...................................................................... .....................................................-...............................-..........................-...........-........................................................................................................ ...............-.................................................................._...... .........-....................-.......................................... ._.........--..............................................................................................-......-..............-....................................--............................---........_............--. ..-..............................................................-...................... ........................................................................ .........-_.._....-.._..........................---....-.................-_...-..................................................................................................................................... ........................................................................................... .............................................................................. 8 Real estate { (a) used for business purposes $ , ........................................................................................................... ................-...............................................................-.... book value (b) not used for business purposes $ / ........................................................................................ .............................................................................. IMPROVEMENTS TOTAL BOOK DESCRIPTION OF PROPERTY NATURE OF BOOK VALUE VALUE IMPROVEMENTS 1 .......................................................... ...........................................-..........-..-............ ..................................~..........................._................................. .......................................................... ................................................................................ 2 -_..................-..-..---_.._...---..--_............_..-..- ....-.............-....-...._..-..-.-...--... .........__...._--_....................-..................-..-_.... .........-......................-.............-..---....--..--.............-....................-....-....-..----....-..-.......-....-...... 3 ................................................................................. ....................................................... ......................................................................... .. ...-..............................-....-..............---..............-.....-..-........-........~......_..-...._..._......----............... 4 ........................................................ ....................................................................... ............................................................................................................................................. ............................................................................... 5 .............................................................................. -..--....-..............-............................... ........... ....~.....-......_..... ............. ............... ......- ........................-.................................................................................................................................... 6 ....................~........................... ...................... 7 ........-.. -.. ...... ............................ .............. ............ .................. .......... ....-.............. .......... .....~............ ............................................................................... ................................................... LOCATION HELD IN WHOSE ASSESSED AMOUNT OF NAME VALUE ENCUMBRANCES 1 ..........................................-.............................._.. .......................................................... ........................................................................ ....................-.............-........................................................................................................................ 2 ..-...-.....--............................................................. ......................................................... ........................................................................-.. ............. ....- -~... ..... .......... ................ ........ .......................... ................. ....... -................. ....-............. 3 - -~ - _....~.... ..... ...............-..-- --~ -....... ---......--. --- ---........ --~ - .--_..-. ......... -....... ..................................................-........................ ..........- - -- ~.._......_..... .-- ...-.. ........ ......... - -............. -..... -. -.. -. _.._..................~....- --.... ...---..-- 4 ............................................................... ..... ~.......... ....-..... ....... .............. ..... ...... .......... ............. ........... .........oOoO..... ........... .........~............ ............ .......................................................................... ........................................................... 5 ..-..-..-................................................................. .........................-.-..-......-........... .... .................. ~.... ~....... ...... ....................-.... ...... ..-..-..----....-..............................................................----...--...-.............-..-................................. 6 -.....--.................-.................................................. .........-........-............--..__....._-..- .... .......... .......... ........~.... ..-.. -.. .--........--...... ..... 7 ... - -.... -... .--.. .~........................... .................... ....-............ - -..- -. -. -- ..----...... ........ ...... ............... .....- . l.ss1 ~(..paratcly cach item amounting to 10 pCTCl-nr or more of the total and combine the remainder. ~\ S:\Sydney\WPDOCS\mi.sceUaneousIMASTER\divB.wpd B-117 DETAILS RELATIVE TO ASSETS (Continued) ~9 Stocks and bonds (a) Listed - present market value $ " ................................................................................ ................................................................................................ (b) Unlisted - present value $ ............................................................................................... ............................................................................................ ILIST NT. OR PRESENT DESCRIPTION ISSUING COMPANY DIY PAID PAR MARKET QUANTITY AMOUNT VALUE DATE % VALUE 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 ESCROW 1 ......................................~...................... ..........~............~....... ~ ~.. ...... ............................... ........ ~................. ~.................. ".. .......... ........................................................... ......................... .......~............................... ....~................... .......................................... 2 .... ......... ........... ...~.............................. ..... ~ - ~ ......... .....~.. -............. ...................................... ......~.............. ~ .............. ~....~........................ .................... ........ ~.. ............................. ............. ........... .............. ................ ~~.... ~.... .......... ............ .......... 3 .......................................... ~....~......... -............. ........... ................. ~.................. ~...... ..~....................... .................................................. .......... ~"."""."."".""""""".". ....~...._................. ....................................... ........................................................... 4 ........................................... .................................................~....... .............~............................ ....~~.... ~...~.................... ....~.................~..................................................~.... ........~............ .......... ...... -................................ _.......~.. ~................ .......... 5 .............. ...-~......-- ....~- ...~... - -.... ~...... ~......... ~........ ~... -........ ............. ~. -................. - ~......... - -........ - _..~.. -.. -............. -... - _......~............................... ~.. ~............ ~......... - -.... -.................... .......... -- ~......-... ~.,,"""."""""~."."". _..- ~.......... 6 ....................................................... ... ......... ........ ................ ...~.................. ... ............... ............ ............ ..... ........ ...-.. ...... ......... ...~.... ............. ..... ....~....................... ..~.............. ...-........ ........ ......... .......... ......... .. .....................~.. ....... 7 Materials 1n stock and not included 10 Item 4, Assets: 10 (a) For use on uncompleted contracts (present value) $ ..-..........................-- ..-~......-~ ............ ........ ......... ............~...... ~... ................ ...... ............ (b) Other materials (present value) $ .......... ...............~...................... ............ .................~.................. .................. ...................... ...... ..........................~.............. ....................... PRESENT VALUE DESCRIPTION OF MATERIAL QUANTITY FOR UNCOMPLETED OTHER MATERIALS CONTRACTS . .......~.... ..................... ....~......... ......................... ....... .......... ............... ............................. .............. .................................................. ..~~... ..~........................ ................~.. .............. ............................. ...... .............................................................................................. . -........................ ~...... -..- ....~................~............ ~...... ..... ~.... ............................ ~... ~ .......... .....~ ~................................. ............ ~............... ......... .............~.. ......~........................................... ........... ~.................. ~ ~...................... ~....... ~..........~............... ....~......... _..................~ ~............................ ~............................ ~......... ~........... ~... -... ........ ... .~..~......._..~ .....-...... ......~...... --~.......... ............ ........ ..-~ ........................... ........-.......... .............._.................................................~....~.................... . ........ ......... ..-............. ....... ...... ......~ ........................ ....... ........................................ ..................................................................... .........................................................................~....~............. . ........~... .......... ....~.. ............... .......................... .............. ...... 11* Equipment at book value $ . ~.. ~. -...... .............. ~........................... -.. ~....... - ~~........ ..-............. ~..~........~ ~....... ~.... ~"."."""""""."" ........ . ......~......... ......................... ...~....... ................................... QUANTITY DESCRIPTION AND CAPACITY OF ITEMS AGE OF PURCHASE DEPRECIATION BOOK ITEM PRICE CHARGED OFF V ALUI ...................................~......... ..... ....... ..~......... ......................... .................... ............ ............. ...... .~.............~............. .....~... ............ ......... ~........... ......~.. ................................................. .... ............. ........ .............~ ...... ......... ....~.. ......~..~......~. ..... ..........-...........-.................... ..............~.... - ~.... -.. _...........-..~.............................. .................... ~...........................~................... ............................... ................................................ .. ........ .....---......- ..... ......- ......... -~. ......-..- . .....-~......~..~.... ............................................ .. ......... ....~......... .............................. ......... -.............. ......- _...........- .................. ............ ...... ........ ........... - ........~.......... .... .......... ......... .........~........~... .............. ........ .......... ..................... ....~...... . ..................~~.. . . r\ Are there any liens against the above? If so, state total amount >I: I f two Of more items 'llrc lumped above, give the sum of their ages. ~\ S:ISydneyIWPDOCSlmiscellaneous\MASTERldivB.wpd B-118 $ .. ....~......~ ........~.. ......... .... ..... ~.....- ...... ................. 12 - ~ , 1~ DETAILS RELATIVE TO ASSETS (Continued) r FurnitUre and fIxtures at book value ...m..___.__..m..........__....___..m..___._m_m.____.____....__ $ mm_______...__..________._____._m___..__._._ Other as se ts _. _.... _ _.. _ _... .._ _.... _ _.._ _ ___ __ _ _._ _ _ no _ _ _ _ ___.. _.._......... no.. -..... --.. - -..... - -. - - - - - - - - - -.. - - -.... -..- - - $ . - - - -... -.... -.. -.. - -..... -...- ... - -. .--.- --.. -. -- DESCRIPTION AMOUNT ...___...................u............_..................................................................-..............---..---..............................................................................---.....--................................................ .....................................................................-.............-...... ................--..........-..............--........-..........................--....--..............----............---.........--..............-.................--...-.............--........--...............-..................-........-..............................................-- .......................................................................................---... I Total Assets: ~r (a) To banks, regular $ ---.........................................................--....-....-........ ....... ~... ~~. ~....... ~ ~......... ..... ............ ~."........ ~.. ................................ ~ 1 { (b) To banks for certified checks ............................................................................................................... $ ....................................................................... (c) To others for equipment obligations $ ....................................................................................... ................................................................... (d) To others exclusive of equipment obligations ................................................................ $ ........................................................................ TO WHOM: NAME AND ADDRESS WHAT SECURlTY WHEN DUE AMOUNT ..... ....... ........................ ............ .......................~.... .............................. ................. ........................................................ .............................................................. ...............................................................................-.. .....................................................................................-........................................................ .................................................................... ..................................................................... ................................................................................ { (a) Not past due , $ 2 ..................................................................................................................................................................... ....................................................................... (b) Past due $ ...................................................................................................................................................................... ............................................................. TO WHOM: NAME AND ADDRESS FOR WHAT DATE PAYABLE AMOUNT ........................... ................................ .......... ................ .......~. ............ ..._......- ............................. ..... .......... _..~.."M.. .. ...... .......... ..................... ............. .~. ...... ......................................................................... '\ '1.-" -.. -.- -.. -..... - - - .-........ - -. -.. -- -. -. -. - - - - -.--- ..-.- - -. - - _.- - -. -- ............................................................... .................................-............................. ..... .............. ~.................................... ................................ 3 Real estate encumbrances (see Item 8, Assets) $ ................................................................................ ............................................................................... 4 Other liabilities $ ........ .......... ............ ..... .~. ......... .............. ....... .................... ..... .... -.. ......... ....... ....... ........ ......~ ....... ......... ..............................................................-............ DESCRIPTION AMOUNT ................ .............. ... ............................... ................... ............ - ..... ...... ............. .... ............... ...... .................... ............. ........... .... ............~......... ....... ...... ....-...... .................................................................................... .................................................................................................................................................................................................................................................................. ......................................................................-............. 5 Reserves $ ....................................................................................................................................................................................................... ................................................................................. INTEREST I INSURANCE BLDGS & FIX PLANT DEPT. TAXES BAD DEBTS $ 1$ $ . $ $ $ 6 up{ (a) Common $ ................................................................. Capital Stock paid ........-........................................................................................................................ (b) Preferred $ ............................................................-................................................. ................................................................... 7 Surplus $ ..........................................-.............................................................................................................................................................. .................................................................................. I Total Liabilities: DETAILS RELATIVE TO LIABILITIES S:\Sydn"i\WPDOCS\mlscellaneousIMASTER\dlvB.wpd B-119 If a corporation, answer this: ~ J-l. f' Amount for which incorporated . 7l~.~~h;....:lh.~!-!:?~..']./...Dq!t.f!:.(.~....l..~.~h~:!.b.............................................................. . I .' L I'}{ h C<.' ~apital paid in cash .l/.!l ~.l.7 ...!::6.~:!:!.'?{~!].i.!?p.I!.!!.!..~... r.........~~:!........ ... ......... ........... ........ $ ...2 .c:.L.~.'?Q.:.:..... ....... ................ .... When incorporated .......................It... ..~..3.:?:.:...(..?..?..F...... ......................................................-.... -.. ... ....... ........ .......................... ........ / ndAJinfl In what state ....................-...............................................................................................................................................................................................--..........................-..............................................---.................................................................. Names and tides of all persons having authority to execute and receipt estimate vouchers and to conduct other business for the corporation, including its officers, the signatures of whom are legally binding. IYJ e , V" ,., J.. (J I't"\ DO' .s ................. ....... ..... ...l~~:. .t;: 'j~"'l.;':~~'~""'" ..... ........ ..................... ........... .................. ................ ..................... .... .............................. ...................................c.~.;:.;.....&.~.."'Ii;.~...................................................................................................................................................... ..........................................................................................---......................................--...........................................-..........................................................................................-............................................................................................................ .-........................-.......-...........-..........-.........................-....-...............-..........................................................................................................................................................-..................................................................................................... ...............................-...............................................-.......-.........................-.-.................................--.........................-...-.........................-................................................................................................................................................ Do you have the necessary "certificate of authority" to transact corporate b~iness in this state, under the terms of Chapter 215, Acts of 1929, and acts amendatory thereto? .................Y.?..................................................................................... If a co-partnership, answer this: Date of organization ............ ........ ....... ......... ..... ...... .......... .................................... .......... .... ....... ............... ...................... ... .......... ... ........... State whether co-partnership is general, limited or association .................................................................--..........-.................................-....................-........--.........-................. Give the names, addresses and proportional interests of all parties ........................................................................................................................................................................................ NAME ADDRESS SHARE $ ........................................................................-................................ ............................................................-.....................................-...........................................................-..-..................... ..............................-.......................-....................................- $ ....................................................................................................... ..........................................................................................................................................-.................................. ............................................................................................. $ .. ~-_..__. ....... ..--.... .......-....... ......... .......... ......... .-....... -. .. ....... -.. ...... ..-.....--................ ....-.......... -.......... ................... ...-..... .......... ............-........... .......... ......... ............................... ..... ...........................-........................ $ .................................................................................................. -...............................................-.......................................-............................................................................. ...............................................................................-.......... $ ........................................................................-.....................-.. ..................................................................-................................................................................................................. ....................................................................................... $ ..........................................................................................-....... ...........................................................................................................................-............................................ .........................................................................-...........-. $ ............-.....-......-................-......................................-........ ........-.......................................................................................................................................................................... ...........................................-................-.......................... $ -................................-................................................................- ......-.................................................-...................................................................-........-...................................-.... ...............................................-...............-........................ ~\ S:ISydneyIWPDOCSlmlscellaneousIMASTERldlvB. wpd B-120 The name of the partnership firm under which the above partners are operating is .......--..................................................................................................................................................................... Gi~~.;;~~~.;;a'citi~;.;;f.;.n.p~~~.~~.~ .h;~~g.;~i:h~ritY.i:~.~;~~;t~.~;;;j"~~~cipt~;.~t~..;-,~:;;;;;h~~~.;~d.i:~. ~~~d~.~i:. ~i:h;;:.b~;l~~~;.f~;'th~p~m~~~.hip:.i:h~ ('ratures of whom are legally binding. .............--.....................................-..................-.................................................................................................................................................................................................................................................................................................................................................. ............................ ........_.......... _........ .......... ...................._.. _.._..................... ............... .............................. _.........n........... ................. ..................... .............................................................. ~ ~...... ~..... ~............. ~...... ~."."".." ........ ~... ~.... ~~. ~..........~. ~. ~.. ~ ~~. ... Th~'~~d~~ig;;~d'h;;:~by'd~~i~~~'th~t.th~.f~;~g~~g"i~.~' tr;;~;t;w;;;~~t.~fi:h~.fi~;~.~i;j.~~;;di.ti~~."c;Tth~. ~di~d~;C~~~p~;tr;~;~hlp.~~. ~~q;~~;ti~;;.h~;~i~ 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 Hrm name and signature of all partners. A corporation must give full corporate name, signature of official and affIx corporate seal. ........ ..................... ~............................ .............................................. ~.....~.. ...... ~....... ~."." ~~........... ......... .................~... ~.. ~.. ~.. ~........ .............. ~ ~........ ~.................. ................. ~................. ~....... ... - -...... -...... - - -.... -.. ~... _.......-.....- -.o.o.. _.o.o ~ ~ - ~..........................o ~.ooo".o"oo."".o.".o .....o.ooo.oo.o............ -.... ...................oo.............oo .....~...........o............ ~......... ~......... ~.~...o... ~. ~.... _..~.oo.... ~..... ~..... ~.. ~.............. Affidavit for Individual COUNTY OF ............__...............................m) ) SS: ...... ................................. ......... ) STATE OF ..............................n.................._...................................m......._.........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_ ~ ~................. ~.......o..~"..""..""".""""""".."."""""OO ................ .......... ~ ~.._.. ~ (Applicant must sign here) Subscribed and sworn to me this .........00...................... day of ................... 20 ..'.00..00'" .oo...ooo.....o....o...o..oo...o _......o.....o..................oo.............~........ ~. -... ~..................... ~ -.... ~. _........o..~..............o......oo. ~ ......... ~. Notary Public Affidavit for Co-Partnership ~TATE OF 6, ; COUNTY OF .. .......................... ..... .......... ..... ) ) SS: ...... ............00. ........................... ) _............._....--..--n.-......-.......--n....--..--m...........n..............._..........n._...being duly sworn, deposes and says that he is a member of the firm of n_m............_______....n__._....__...............n...n...........................................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 foregoing interrogatories are true. .......o................... ~. ~................................................ ~ ~ ......~...................... ~.......... (Member of firm must sign here) Subscribed and sworn to me this .............................___.dayof 00.._..'."''''.''' 20.00.......... .............o.......o...o.....o.... ............................... ~...o.o.o..o.".o..._.o.""""".."...."" ..... ........... ........ ~....... ....... ~ ...... ~..........o COUNTY OF Notary Public :r: III Affidavit for Corporation ........ ... ..........00........ .... .00.......... ) Cb-ff/ll( ) SS: ."'00.' _ ___... .............. ........ ...--...... ) STATE OF :::::::::::::::T.~IJ;:~:~f?4::[~:~:~~:~:::::::::::::::::::::::::~~~~~t~Ji~':~~:~~~s::e~:~e~a~~~::::~:; :::;:~~ft~:~ ~~fso;=arof with the books of said corporation showing its financial condition; that the foregoing financial statement, taken from the books of . corpo ation is a true and accurate statement of the financial condition of said corporation as of the date thereof an~tha ns r ore 1 1I1terr gatories are true. . . IJ. j .. . (0[& ~~.m~~t'~i"m... . .m......m...."- s:~."'.~~~_~H4~~Of~::~~_- 20 (22.... .. Notary Public ______/"""'\ S:ISydneyIWPDOCSlmlscellaneous\MASTERldlvB.wpd B-121 G. ;;'~ -~ r, U.S. ENVIRONMENTAL PROTECTION AGENCY CERTIFICATION OF NONSEGREGATED FACILITIES (Applicable to federally assisted construction contracts and related subcontracts exceeding $10,000 which are not exempt from the Equal Opportunity clause.) ~ '7: The federally assisted construction contractor certifies that he does not maintain or provide for his employees any segregated facilities at any of his establishments, and that he does not permit his employees to perform their services at any location, under his control, where segregated facilities are maintained. The federally assisted construction contractor certifies further that he will not maintain or provide for his employees any segregated facilities at any of his establishments, and that he will not permit his employees to perform their services at any location, under his control, where segregated facilities are maintained. The federally assisted construction contractor agrees that a breach of this certification is a violation of the Equal Opportunity clause in this contract. As used in this certification, the term "segregated facilities" means any waiting rooms, work areas, rest rooms and other storage or dressing areas, parking lots, drinking fountains, recreation or entertainment areas, transportation, and housing facilities provided for employees which are segregated by explicit directive or are in fact segregated on the basis of race, creed, color, or nation origin, because of habit, local custom, or otherwise. The federally assisted construction contractor agrees that (except where he has obtained identical certifications from proposed subcontractors for specific time periods) he will obtain identical certifications from proposed subcontractors prior to the award of subcontracts exceeding $10,000 which are not exempt from the provisions of the Equal Opportunity clause, and that he will retain such certification in h is files. 1;l~II"'07 Date ;n e / v: "" L,.......,. 1'1"/ ~? eI'. Name and Title of Signer (Please type) Te-",^, C.".{../".c-f. "1) L/,( .., /fJ 7 1". ~ Firm Name NOTE: The penalty for making false statements in offers is prescribed in 18 D.S.C. 1001. OEE-1 (11/79) ~r"\ D-1l9 ~, r...; -.< ~\ I _ -r--, \',-~l. ...\ ~.~. NOTICE TO LABOR UNIONS OR OTHER ORGANIZATIONS OF WORKERS NONDISCRIMINATION IN EMPLOYMENT TO: (Name of union or organization of workers) The undersigned currently holds contract(s) with TIP""'''.;' Je.f>J,t' ~./I",;II') ;rAl (Name of Applicant) involving funds or credit of the U.S. Government or (a) subcontract(s) with a prime contractor holding such contract(s). You are advised that under the provisions of the above contract(s) or subcontract(s) and in accordance with Executive Order 11246, as amended, dated September 24, 1965, as amended, the undersigned is obliged not to discriminate against any employee or applicant for employment because of race, color, creed, or national origin. This obligation not to discriminate in employment includes, but is not limited to, the following: HIRING, PLACEMENT, UPGRADING, TRANSFER, OR DEMOTION, RECRUITMENT, ADVERTISING, OR SOLICITATION FOR EMPLOYMENT, TRAINING DURING EMPLOYMENT, RATES OF PAY OR OTHER FORMS OF COMPENSATION, SELECTION FOR TRAINING INCLUDING APPRENTICESHIP, LAYOFF OR TERMINATION. This notice is furnished you pursuant to the provisions of the above contract(s) or subcontract(s) and Executive Order 11246, as amended. Copies of this notice will be posed by the undersigned in conspicuous places available to employees or applicants for employment. I;J" /1"07 (Date) OEE-2 (11/79) D-120 ~___ kr,f Ii Instructions Under Executive Order 12549, an individual or organization debarred or excluded from participation in Federal assistance or benefit programs may not receive any assistance award under a Federal program or a sub-agreement thereunder for $25,000 or more. Accordingly, each prospective recipient of an EP A grant, loan, or cooperative agreement and any contract or sub-agreement participant thereunder must complete the attached certification or provide an explanation why they cannot. For further details, see 40 CFR 32.510, Participants' responsibilities. Where to Submit The prospective EP A grant, loan, or cooperative agreement recipient must return the signed certification or explanation with its application to the appropriate EP A Headquarters or Regional office, as required in the application instructions. A prospective subcontractor must submit a completed certification or explanation to the prime contractor for the project. How to Obtain Forms: EPA included the certification form, instructions, and a copy of its implementing regulations (40 CFR Part 32) in each application kit. Applicants may reproduce these materials as needed and provide them to their prospective prime contractor, who, in turn, may reproduce and provide them to prospective subcontractors. Additional copies/assistance may be requested from: Compliance Branch Grants Administration Division (PM-216F) U.S. Enviromuental Protection Agency 401 M Street, SW Washington, DC 20460 (Telephone: 202/475-8025) -------,r' D-121 ".....~ t:> (\ ~r, United StatesEnyi~on~ent~IProtection Agency Washington, DC 20460 Certification Regarding Debarment, Suspension, and Other Responsibility Matters The prospective participant certifies to the best of its knowledge and belief that it and its principals: (a) Are not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from covered transactions by any Federal department or agency; (b) Have not within a three-year period preceding this proposal been convicted of or had a civil judgement 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; (c) Are not presently indicted for or otherwise criminally or civilly charged by a government entity (Federal, State or local) with commission of any of the offenses enumerated in paragraph (1 )(b) of this certification; and (d) Have not within a three-year period preceding this application/proposal had one or more public transactions (Federal, State or local) terminated for cause or default. I understand that a false statement of this certification may be grounds for rejection of this proposal or termination of the award. In addition, under 18 use Sec. 1001, a false statement may result in a fine of up to $10,000 or imprisonment for up to 5 years, or both. (YJe-Iv:" i, ..,."'~ ~. tn.",.)~ /t'-'\ ('_./.""....1..")1 LtC. Typed N Repre ntative /:J.- /1-07 Date o I am unable to certify the above statements. My explanation is attached. EP A Form 5700-49 (11-88) D-122