HomeMy WebLinkAboutStandard Qualification Questionnaire (SQQO) STATE OF HAWAII
STANDARD
QUALIFICATION QUESTIONNAIRE
FOR
OFFERORS
issued by the
PROCUREMENT POLICY BOARD
STATE OF HAWAII
June 16, 2003
To be filed with the procurem ent officer calling for offers in accordance with Section 103D-310, HRS, as amended. Submitted By Address Date STANDARD QUALIFICATION QUESTIONNAIRE COVERING EXPERIENCE, EQUIPMENT AND FINANCIAL STATEMENT OF OFFERORS. THE OFFICER CALLING FOR OFFERS MAY REQUI RE THE OFFEROR TO FURNIS H ADDITIONAL INFORMATION NOT SPECIFICALLY COVERED HEREIN. ALL ITEMS MUST BE ANSWERED AND OMISSIONS MAY BE CONSIDERED GOOD CAUSE FOR UNFAVORABLE CONSIDERATION. SPO Form-21
GENERAL INFORMATION
1. The statements contained in this Questionnaire are being furnished for consideration in submitting an offer for the following project: (a) Project Title (b) Location (c) Bid Opening Date 2. The Questionnaire is being submitted in behalf of:
EXPERIENCE QUESTIONNAIRE
4. Have you ever failed to complete any work awarded to you? If so, state when, where and why? 5. Has any officer or partner of your organization in the past five (5) years been an officer or partner of some other organization that failed to complete a contract? If so , state name of individual, other organization and reason therefore 6. Has any officer or partner of your organization in the past five (5) years failed to complete a contract handled in his own name? If so, state name of individual, name of Owner and reason therefore. 7. In what other lines of business are you financially interested? 8. For what corporations or individuals in the past fi ve (5) years have you performed work, and to whom do you refer? 9. For what counties within the State of Hawaii ha ve you performed work and to whom do you refer? 10. For what Bureaus or Departments of the State government have you performed work and to whom do you refer? 11. Have you performed work for the U. S. Government? If so, when and to whom do you refer? 4
12. Have you ever performed any work for any other governmental agencies outside the State of Hawaii? If so, when an d to whom do you refer? 13. What is the [construction] experience of the principal individuals of your organization? Individual’s Name Present Position or Office Years of Work Experience Magnitude and Type of Work In What Capacity? 5
EQUIPMENT QUESTIONNAIRE
6. Do you intend to do grading on the proposed work with your own forces? If so, give type of equipment to be used 7. If you intend to sublet the grading or perform it through an agent, state amount of sub-contract or agent's contract, and, if known, the name and address of sub-contractor or agent, amount and type of his equipment and financial responsibility 8. Do you intend to sublet any other portions of the work? If so, state -amount of sub -contract, and, if known, the name and address of the sub -contractor, amount and typ e of his equipment and financial responsibility 9. From which sub-contractors or agents do you expect to require a bond? 10. What equipment do you own that is available for the proposed work? Quantity Item Description, Size, Capacity, Etc. Condition Years of Service Present Location 7
11. What equipment do you intend to purchase for use on the proposed work, should the contract be awarded to you? Quantity Ite m Description, Size, Capacity, Etc. Approximate Cos t 12. How and when will you pay for the equipment to be purchased? 13. Do you propose to rent any equipment for this work? If so, state type, quantity and reasons for renting 8
FINANCIAL STATEMENT
BALANCE SHEET (Continued) Liabilities and Stockholder’s Equity Current liabilities: Current portion of long-term debt (1) Accounts payable (2) Billings in excess of costs and estimated earnings on uncom pleted contracts (3)
Accrued liabilities and other (4)
Sub-Total Current Liabilities
Long-term debt, net of current portion (5) Sub-Total Liabilities & Long-term Debt: Stockholder’s equity: Capital stock (6) Additional paid-in capital (7) Retained earnings Treasury stock (8) Sub-Total Stockholder’s Equity Total Liabilities a nd Stockholder’s Equity $ $ ( ) $ $ 10
DETAILS RELATIVE TO ASSETS (1) Cash and cash equivalents: Financial In stitution Type of Account Amount $ (2) Short-term investm ents: Type of Security $ Cost $ Unrealized Gains $ Unrealized Losses $ $Estimated Fair Value (3) $ Accounts receivable (list major debtors): Completed Contracts Name Description $ Com pletion Date $ $ Contract Am ount $ $ Am ount Receivable $ $ Other than completed contracts Amount Name Description Due Date Receivable $ Less allowance for doubtful accounts (4) Inventories Description ( $ ) $ Cost Market Value $ Lower of Cost or Market Value $ $ $ $ 11
(5) DETAILS RELATIVE TO ASSETS (Continued) Costs and es timated earnings in excess of billings on uncompleted contracts Name Description Completion Date Contract Amount Costs and Estimated Earnings to Date $ $ $ Billings to Date Costs a nd Estimated Earnings in Excess of Billings $ (6) Prepaid expenses and other $ Description $ $ $ $ Am ount $ (7) Land Description Location Amount $ $ (8) Buildings Description Location $ Am ount $ (9) Vehicles, m achinery and equipment Description Amount $ $ (10) Furniture and fixtures Description Amount $ $ 12
DETAILS RELATIVE TO ASSETS (Continued) (11) Cash surrender value of life insurance policies Key Employee Insurance Company $ Policy Am ount $ Paid-Up Additional Insuranc e $ CSV Am ount Less loans p ayable $ $ ( $ ) (12) Deposits and other Description $ Am ount $ 13
DETAILS RELATIVE TO LIABILIT IES AND STOCKHOLDER’S EQUITY (1) Current portion of long-term de bt (maturing within 12 months) Security Lender Description Pledged Due Date Amount $ $ (2) Accounts payable (list major creditors) Name $ Past Due Amount $ Amount (3) $ Billings in excess of costs and estimated earnings on uncompleted contracts Name Description Completion Date Contract Amount Costs and Estimated Earnings to Date $ $ $ Billings to Date $ Billings in excess of costs and Estimated Earnings $(4) Accrued liabilities and other $ Description $ $ $ $ Am ount $ (5) Long-term debt, net of current portion Lender Description Security Pledged Due Date $ Amount $ 14
DETAILS RELATIVE TO LIABILITIES A ND STOCKHOLDER’S EQUITY (Continued) (6) Capital stoc k No. of Shares No. of Shares Issued and Type of Stock Class Authorized Outstanding Par Value Amount $ $ $ (7) Additional paid-in capital Description Amount $ $ (8) Treasury stock Type of Stock Class No. of Shares $ Cost $ 15
STATEMENTS OF INCOME AND RETAINED EARNINGS For the Years Ended , 20 and 20 Contract revenues Costs of contracts Gross income from contracts General and administrative expenses Income from operations Other income (expense) Income before income taxes Income taxes Net incom e Retained earnings, beginning of the year Retained earnings, end of the year 20 $ $ 20 $ $ 16
If a corporation, answer this: Capital paid in cash, $ When Incorporated In what State Date registered in Hawaii I f a partnership, answer this: Date o f organization Date registered in Hawaii State whether partnership is general or limited Presi dent's name Vice-President's name Secretary's name Treasurer's name Nam e and address of partners: Age The und ersigned hereby declares: that the foregoing is a true statement of the financial condition of the individual, partnership or corporation herein first named, as of the date herein first given; that this statement is for the express purpos e of inducing the party to whom it is submitted to award the offero r a contract; and that any depository, vendor or other agency herein named is hereby authorized to supply such party wi th any information necessary to verify this statement. NOTE: A partnership must give firm name and signatures of all partners. A corporation must give full corporate name, signature of official, and affix corporate seal. Affidavit for Individual STATE OF HAWAII COUNTY OF _________________________________________________________________ being duly sworn, deposes and says that the foregoing financial statement, taken from his books, is a true and accurate statement of his financial condition as of the date thereof a nd that the answers to the foregoing interrogatories are true. Sworn to before me this (Applicant must also sign here) day of 20 Notary Public Affidavit for Partnership STATE OF HAWAII COUNTY OF __________________________________________________________________ being duly sworn, deposes and says that he is a member of the firm of ______________________________________________________________________; and that he is familiar with the books of the said firm showing its financial condition: that the foregoing financial statement, taken from the books o f the said firm, is a true and accurate statement of the financial condition of the said firm as of the da te thereof and that the answers to the foregoing interrogatories are true. Sworn to before me this (Members of firm must also sign here) day of 20 Notary Public Affidavit for Corporation STATE OF HAWAII COUNTY OF ___________________________________________________________________ being duly sworn, deposes and says that he is ________________________________ of the ___________________________________________________________, the corporation described in and which executed the foregoing statement; that he is familiar with the books of th e said corporation showing its financial condition; that the foregoing financial statement, taken from the books of the said corporation, is a true and accurate stateme nt of the financial condition of said corporation as of the date thereof and that the answers to the foregoing interrogatories are true. Sworn to before me this (Officer must also sign here) day of 20 Notary Public 17
Doc. Date: No. of Pages: Notary Name: Judicial Circuit Doc. Description: State of Hawai‘i Standard Qualification Questionnaire for Offerors for County of Hawai‘i, Department of Public Works Notary Signature Date 18