Revised 05/14

ALABAMA DEPARTMENT OF TRANSPORTATION Montgomery, Alabama, 36110

Confidential Financial Statement and Equipment And Experience Questionnaire

Type of Organization:

An Individual A Partnership A C Corporation

S Corporation A Limited Liability Company Other

Organization Name: ____________________________________________________________

State of Formation: _____________________________________________________________

Street Address: _____________________________________________________________

_____________________________________________________________

Mailing Address: _____________________________________________________________

_____________________________________________________________

Vendor E-Mail: _____________________________________________________________

Telephone No.: __________________________ Fax No.: __________________________

Federal Employment Identification No.: ___________________________________________

State of Alabama Licensing Board No.: ___________________________________________

FOR ALDOT USE ONLY

Contractor ID: ___________________ Contract Limit: ___________________ Expiration Date: ___________________ Receipt Date: ___________________ Approval Date: ___________________

NOTICE TO PREQUALIFICATION APPLICANTS

In accordance with Section 23-1-56(H), Code of Alabama 1975, "It shall be unlawful for any

applicant for qualification to knowingly make a false statement with respect to his financial

worth in any application for qualification, financial statement or other written instrument filed

by him with the Alabama Department of Transportation under the terms of this chapter or the

rules and regulations adopted pursuant thereto. Any persons violating the provisions of this

subsection shall, upon conviction, be fined not less than $100 nor more than $500, and shall be

disqualified from submitting bids for a period of two years following the date of conviction."

DO NOT REMOVE ANY PAGES

FROM THIS QUESTIONNAIRE

INSTRUCTIONS

READ CAREFULLY BEFORE ATTEMPTING TO COMPLETE THIS FORM

1. The financial statement must be prepared by a Certified Public Accountant or a LicensedPublic Accountant who is neither directly nor indirectly interested nor connected with the contractor's business. The certification on page 11 or an accompanying certification as to the validity of the financial statement must be personally signed by the preparer together with his/her State of registration and certificate or license number.

2. Only audited or reviewed financial statements will be accepted. If the CPA has previouslyreviewed a financial statement, he/she can issue a compiled report on financial statements for the same period that are included in a prescribed form that calls for a departure from Generally Accepted Accounting Principles. (See footnote 2 of Statement on Standards for Accounting and Review Services, No. 3.) He/she must attach to the prescribed form general purpose financial statements that the accountant has reviewed or audited or a review report can be issued on the balance sheet referring to pages 4 through 15 of this questionnaire as supplementary information in the report and include the disclosures (footnotes) that relate only to the balance sheet. A statement of a Certified Public Accountant shall not be required for the issuance of certificates under $50,000.

3. Do not substitute your own form. No other statement, form, audit or information will beaccepted. Each item must be set forth in full and wherever explanations are requested they must be given in detail. The amounts shown for each item must be actual, as obtained from bank statements, etc., and not approximate amounts.

4. The signatory statement on page 1 must be signed by the individual if the applicant is anindividual, by the duly authorized officer if a corporation, and by a general partner if a partnership. Execute Worker's Compensation Certificate on page 2. Execute proper affidavit on page 15.

5. Prequalification applications will not be accepted if more than sixteen (16) months havetranspired since the date of the financial statement. The application must be filed at least (14) days prior to the date of opening of bids on which the contractor desires to submit a bid. A contractor not pre-qualified will not be issued a bid proposal but, if requested, will be issued a sample bid proposal.

6. A new application for qualification must be completed and submitted each year; more oftenif, in the opinion of the Department, the financial position of the contractor is such as to warrant it. A new application is also required in the event a significant change in the structure of the firm such as a change of ownership or incorporation of a non-incorporated firm, or a subsequent event that is material and adversely affects the financial position of the contractor.

7. Unless exempted by the State Licensing Board for General Contractors, a license to dobusiness in the State of Alabama must be obtained from said board by the contractor. On projects with no federal funding, no bid proposal will be considered without evidence of such license. On projects with federal participation, proposals will be considered but award will not be made until evidence of such license is furnished to the Department. (Projects without federal funding typically, but not necessarily, exclusively have the following designations: ST, IA, or 99).

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8. Foreign corporations are those incorporated in states other than Alabama. The applicantmust furnish a certificate of existence issued by the Alabama Secretary of State qualifying the corporation to do business in Alabama. This certificate, in original form, must accompany the original application and all subsequent renewals. On projects with no federal funding,, no bid proposal will be issued without evidence of such certificate. On projects with federal participation, proposals will be issued but award will not be made until the certificate is furnished to the Department.

9. If the applicant has been debarred by the Federal Highway Administration because his/herfirm or any of his/her subsidiaries has an officer, director, partner, agent or employee convicted of any act prohibited by state or federal law which involves fraud, bribery, collusion, conspiracy, violation of state or federal antitrust laws, or material misrepresentation committed in any federal or state jurisdiction with respect to a public contract, applicant will not be approved for prequalification until reinstatement by the Federal Highway Administration.

10. Limited Liability Companies, Sub-Chapter S Corporations, partnerships and individualsmust establish an adequate reserve for income tax liabilities. This contingency must be presented on the department form as a contingent liability (see page 11, item 4). Failure to comply will cause the Department to make its determination as to the amount of the contingency and it will be added to Schedule 17, Other Liabilities.

11. In parent-subsidiary relationships (subsidiaries, affiliates and related companies areconsidered the same) where both the parent company and the subsidiary wish to be separately pre-qualified by the Department, the investment in the subsidiary company must be deducted from the assets of the parent company in computing its adjusted net worth. To facilitate this action, all firms which qualify as a parent company must list all subsidiaries pre-qualified with the Department and the dollar amount of the investment. A subsidiary desiring to bid under its own name in lieu of its parent company must present an unconsolidated financial statement. If not unconsolidated, the statement will be returned.

12. Joint holdings for sole proprietorship applications will be considered at 50% of the value ofthe asset. This includes, but is not limited to, joint bank accounts, land, building ownership, and equipment.

13. At the written request of the applicant, the Department may consider an appraisedequipment valuation, but only when a Department approved appraisal firm certifies that it has personally looked at and appraised each unit of equipment listed. To qualify for appraisal, each piece of equipment appraised must show book value, acquisition date, year manufactured, acquisition cost, manufacturer, model number, serial number and condition (good, fair or poor). The appraisal should be close to the end of the bidder's fiscal year and will be accepted for one year only. The Department reserves the right to make on-site reviews of the appraisals. The form on page 14 must be used to facilitate approval of the appraisal evaluation. A list of acceptable appraisers is available on request.

14. If an applicant has a negative net worth as determined by the Department’s analysis ofhis/her financial statement, the application will be rejected.

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15. After the Department has analyzed the submitted financial questionnaire and relatedinformation and has determined the appropriate ratings, a Certificate of Eligibility showing the dates of eligibility will be issued. The certificate will permit the contractor to obtain bidding proposal forms and plans for any Alabama Department of Transportation project which is within the limits of the contractor's potential, as indicated on his Certificate of Eligibility, subject to any limitations due to present work under contract or pending award.

16. All prequalification ratings issued by the Department will expire (16) months from the dateof the financial statement; however, no ratings will be issued on the basis of a statement that is over (16) months old. The expiration date of current ratings is shown on the Certificate of Eligibility issued to the contractor. A new application must be submitted prior to that time in order for a contractor to maintain continuous pre-qualification. It is not the responsibility of the Departmentif the contractor does not receive the new statement for pre-qualification renewal.Extensions of expiration dates are not allowed.

17. The applicant must indicate on page 10 the owner or owners of the corporation and the nameof the partners if a partnership. If additional space is required, attach separately.

18. Failure to include your depreciation schedule with a complete listing of equipment will causeyour application to be returned and could result in delay of your pre-qualification.

19. For each type of work in which an applicant requests classification, certain major items ofequipment are necessary and the ownership or lack of such will affect the type of work approved. The list of equipment may be checked by the Department and the type of work approved reevaluated. In the event the Department considers the applicant does not have sufficient equipment to perform the work, the application for pre-qualification will be denied. The applicant may request the Department's reconsideration if it is his/her intention to perform the work with rental equipment. This request must be in writing and must include a notarized statement from a reputable equipment dealer. This statement must list all equipment considered by the Department as necessary to complete the work; that the equipment is available; and will remain available for rental during the period of qualification and during the life of any contracts obtained during this period.

20. All forms must be completed in ink or type. Completed questionnaire applications uponreceipt become property of the Department. Mail applications to Assistant Bureau Chief for Contractor Pre-qualification Engineer, Alabama Department of Transportation, Room E-108, 1409 Coliseum Boulevard, Montgomery, Alabama 36110. The Department cannot guarantee confidentiality of your application if it is not addressed as shown in this instruction.

21. Any selection of work classification shown on page v must be substantiated by furnishingevidence of experience in the selected category. Such evidence must include location of the work, project number, contract amount, whether subcontractor or prime, and a brief description of the work.

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22. The Department may suspend for a specified period of time, or revoke, or deny for goodcause, any contractor's qualification to bid. A suspension, revocation or denial for good cause as listed below shall prohibit the contractor from bidding any Department construction contract, regardless of the dollar amount of the bid during the period of suspension, revocation or denial. Such good cause shall include, but shall not be limited to, the following:

A. Lack of competency or experience; or a lack of machinery, equipment or plant; or the lack of financial resources as revealed by the prequalification questionnaire.

B. Fails to promptly reimburse the Department for any overpayment that might have occurred.

C. Fails to promptly reimburse the Department for any proposal guarantee forfeited as a result of the contractor's failure to execute a contract.

D. The contractor is an affiliate of a contractor who has had a Certificate of Qualification suspended, revoked, or denied.

E. The contractor makes false, deceptive or fraudulent statements in the application or in any administrative or judicial proceeding.

F. Affiliated contractors submitting more than one proposal for the same work. The certificate of the affiliated bidders shall be suspended and the bids shall be rejected by the Department.

IV

CLASSIFICATION OF WORK

The Department will consider approving the applicant only in those specific work classifications selected by him/her and confirmed by the Department. An approved contractor may sublet to an approved subcontractor any items or items that will not exceed 70% of his/her total contract, less any specialty items; yet he/she is only required to be approved for that 30% they perform with their own forces. See Standard Specifications. Consideration for bridge classifications will be made only if the applicant completes in detail item 5, page 13. Work classifications are defined as follows:

(1) Major Bridges are those that include movable spans, curved steel girders, multi-level roadways, concrete segmental construction, steel truss construction, cable stayed construction, and bridges over navigable water with a span 150 feet or greater.

(2) Intermediate Bridges are those with span lengths exceeding 50 feet and a total bridge length exceeding 300 feet. An Intermediate Bridge shall not include any of the types of construction listed under Major Bridges.

(3) Minor Bridges are those having span lengths not exceeding 50 feet and a maximum bridge length of 300 feet. A Minor Bridge shall not include any of the types of construction listed under Major or Intermediate Bridges.

(4) Grading (includes clearing and grubbing, topsoil, excavation and embankment, earth retention systems).

(5) Bituminous Hot Mix Structure and Surface Courses

(6) Portland Cement Concrete Paving

(7) Flexible Paving. (Includes base courses, stabilizing, and surface treatments.)

(8) Major Drainage. (Includes storm drains, pipe culverts, box culverts and bridge culverts.)

Many of the following work classifications are incidental to the above major classifications (1 through 8). Thus, if classified in one or more of the above, the applicant will also be considered classified in those work areas that are incidental to his major work classification. For example, grading includes A, C, D, E, F, G, J, L, M, Q, T as listed below:

A. Minor Drainage (includes headwalls, inlets, paved ditches, sidewalks, paved turnouts, curb and gutter, and underdrains)

B. Electrical Work (includes roadway, bridge lighting and traffic signals) C. Traffic Control (signing, lighting and marking) D. Permanent Signing E. Permanent Marking (delineators, thermoplastics and traffic stripe painting) F. Guardrail G. Fencing H. Bridge Painting I. Tunnels (construction/maintenance) J. Grassing, Seeding, Sodding, and Landscaping (erosion control) K. Bridge Repair L. Mowing M. Demolition N. Pilings, Drill Shaft O. Environmental (underground storage tanks) P. Building Construction Q. Drilling and Blasting R. Utilities (water lines, sewerage, gas lines, other) S. Pavement Repair (grouting, sealing, grinding, milling, asphalt rehab, gunite) T. Dredging (hydraulic embankment construction) U. Marine (underwater construction, coffer dams, cathodic protection) V. Geotechnical W. Intelligent Transportation Systems X. Other (specify)

WORK CLASSIFICATIONS

Code Description of Work Requested Approved

Major Work Classifications:

MB Major Bridges IB Intermediate Bridges

MIB Minor Bridges GR Grading HM Bit. Hot Mix Structural and Surface Courses CPV Portland Cement Concrete Paving FP Flexible Paving MD Major Drainage

Specialist or Incidental Classifications:

MID Minor Drainage EW Electrical Work TC Traffic Control PS Permanent Signing PM Permanent Marking

GRA Guardrail FC Fencing BP Bridge Painting

TTM Tunnels GSS Grassing, Seeding, Sodding and Landscaping BR Bridge Repair

MW Mowing DM Demolition PDS Piling, Drill Shaft ENV Environmental BC Building Construction DB Drilling, Blasting UT Utilities PR Pavement Repair DR Dredging MA Marine

GEO Geotechnical ITS Intelligent Transportation Systems

Other (specify)

SIGNATORY The signatory of this financial statement and questionnaire guarantees, as evidenced by the sworn affidavit required herein, the truth and accuracy of all statements and of all answers to interrogatories hereinafter made. The undersigned hereby authorize(s) and request(s) any public official, engineer, architect, surety company, bank, depository, material or equipment manufacturer or distributor or any person, firm or corporation to furnish any pertinent information requested by the Alabama Department of Transportation, deemed necessary to verify this statement or regarding the standing and general reputation of the undersigned. Dated this ________________ day of ___________________________________, 20 ______.

________________________________________________ Name of Organization

By_____________________________________________

________________________________________________ Title of Person Signing

(If Corporation, Give Seal)

Sworn to and subscribed before me this ____________ day of ____________________________, 20_____.

________________________________________________ Notary Public

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WORKMEN'S COMPENSATION

STATE OF _________________________________

COUNTY OF _______________________________

This is to certify that _______________________________________________________________________ of

________________________________________________________ has complied and is complying, in every way, with the Workmen's

Compensation Law and is not in default in the payment of any sums due under the provisions of such law.

________________________________________________ Contractor

By _____________________________________________ Title

Sworn to and subscribed before me this _________ day of _____________________________________, 20______.

________________________________________________ Notary Public

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CONTRACTOR'S FINANCIAL STATEMENT AS OF __________________ Assets

CURRENT ASSETS 1.Cash……………………………………… 2.Notes Receivable………………………... Less Notes Receivable Discounted……… 3. Certified Checks on Deposits for Bids…. 4. Accounts Receivable from completed contracts, exclusive of claims not Approved for payments…………………. 5.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…………….

6. Other Accounts, Receivable……………. 7. Stocks and Bonds………………………. 8. Materials in Stock not included in Schedule 5 ………………………………

(a) for uncomplete contracts (present value)

(b) Other materials (present value)……... 9. Others Current Assets (Attached Schedule)……………………… Total Current Assets………… FIXED ASSETS 10. Plant and Equipment……………………. Less Reserve for Depreciation…………………………… Total Fixed Assets………….. OTHER ASSETS 11. Real Estate…………………………….. Less Reserve for Depreciation…………………………… 12. Other Assets…………………………… …………………………………………. …………………………………………. TOTAL ASSETS…………….

Omit Cents

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Liabilities and Net Worth CURRENT LIABILITIES 13. Notes Payable (a) To banks regular…………………… (b) To banks for certified checks…………………….

(c) To others for equipment…………………………..

(d) To others exclusive of equipment obligations………………………….

14.Accounts Payable………………………. 15.Owning Subcontractors………………… 16.Accrued Taxes………………………….. 17.Other Current Liabilities ….……………………………………. ……………………………………….. .………………………………………. .………………………………………. .…………………………………….… Total Current Liabilities………... FIXED AND OTHER LIABILITIES 18. Encumbrances on Plant Equipment Less amount shown as current above….. 19.Mortgage on Real Estate………………... 20. Other Liabilites………………………… Total Fixed and Other Liabilites… NET WORTH 21. Individual or partnership capital………. 22. Capital stock…………………………… 23.Retained earnings……………………… TOTAL NET WORTH……….. TOTAL LIABILITIES AND NET WORTH………………

Omit Cents

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DETAILS RELATIVE TO ASSETS Schedule 1 - Cash

______________________________________________________________________________________________________ CASH a. On hand ....................................................................................................... $______________________

b. Deposited in banks listed below subject to immediate withdrawal ............ $______________________ c. Elsewhere -(state where) ...............................................................................$______________________ Total .............................$______________________

Name of Bank Location Deposited in Name of Amounts

Total State how much is held in restricted accounts . . . . . . . . . . . $_________________________

*Schedule 2 - Notes Receivable (a) Due within 90 days ……………………………………................................... $_________________________ (b) Due after 90 days ............................................................................................... $_________________________ (c) Past due .............................................................................................................. $_________________________ Receivable From: Name/Address For What Maturity Date How

Secured Amount

Total Have any of the above been discounted or sold? _____ If so, state amount $_____________

*Indicate notes discounted by asterisks.

Schedule 3 – Certified Checks on Deposit for Bids Deposited With: Name/Address For What When Recoverable Amounts

Total Schedule 4 – Amounts receivable from completed contracts exclusive of claims not approved for payment (use additional paper as necessary)

Name/Address of Owner Nature of Contract Amount of Contract Amount Receivable

Total Have any of the above been assigned, sold or pledged? _____ If so, state amount: $__________

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Schedule 5 - Sums earned on uncompleted contracts, as shown by engineer's estimate:

(a) Amount receivable after deducting retainage ................................................................... $__________________ (b) Retainage to date due upon completion of contract .......................................................... $__________________ Designation of Contract and Name/Address

of Owner Amount of Contract

Amount Earned

Amount Received

Retainage When Due

Retainage Amount

Amount Exclusive of

Retainage

Totals Have any of the above been sold, assigned or pledged? _______ If so, state amount: $___________ Schedule 6 - Other Accounts Receivable $____________________

Name/Address of Party from Whom Due

When Due For What Amount Due

Total

What amount, if any, is past due? . . . . . . . . . . . . . . . . . . . . . $___________________ *Indicates items assigned by asterisk.

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Schedule 7 - Stocks and Bonds

Stocks (a) Listed--Book Value .......................................................................................... $___________________ (b) Unlisted--Book Value ....................................................................................... $___________________

No. of Shares

Issuing Company

Name of the Security

Book Value

Date of Last Dividend

Market Value

1. 2. 3. 4. 5. 6. 7. 8. 9. 10.

Who Has Possession

If any are Pledged or in Escrow, State for Whom and Reason

Amount Pledged or in Escrow

1. 2. 3. 4. 5. 6. 7.

Schedule 8 - Materials in Stock and Not Included in Schedule 5

(a) For use on uncompleted contracts (present value) .............................................................. $___________________ (b) Other materials (present value) ......................................................................................... $___________________

Description of Material

Show Location of Material (City, State, Project

Number)

Tested-Accepte

d Inspecte

d Yes or

No

Quantity

Present Value For Uncompleted Other Projects Materials

Schedule 9

Other current assets Description Amount

Totals

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Schedule 10 - Plant and Equipment

List separately all items of equipment which are not included under Schedule 11--Real Estate. Attach depreciation schedule. All equipment must be included in this schedule.

Description and Capacity of Items Including manufacturer, serial no. &

location

Year Manufactured

Purchase Price

Depreciation Reserve

Present Book Value

Encumbrance Amount

Total Note: All information, as listed on this page, must be given separately for each major item of equipment. Small tools and items should be lumped.

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Schedule 11 - Real Estate

Real Estate (a) Used for business purposes ........................................................... $___________________ Book Value (b) Not used for business purposes ..................................................... $___________________

Property Land Buildings and Improvements

Description

Book Value Nature of

Improvements

Cost Depreciation

Reserve

Book Value

1. 2. 3. 4. 5.

Location

Held in Whose Name

Assessed Value

Encumbrances Maturity Date Amounts

1. 2. 3. 4. 5.

Note: Leasehold property discounted 100%.

Schedule 12 - Other Assets Full Description Remarks Amounts

Total Assets ___________

Subsidiary and Affiliated Companies

Name - Address Explain in Detail Exactly Your Connection with this Company

DETAILS RELATIVE TO LIABILITIES

Schedule 13 - 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 ................................................................... $___________ Total ................... $___________

To Whom: Name and Address What Security When Due Amount

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Schedule 14 - Accounts Payable

(a) Not past due ................................................................................................................... $___________________ (b) Past due ......................................................................................................................... $___________________

To Whom: Name and Address For What Date Payable Amounts

Note: All under 10% of total may be lumped together.

Schedule 15 - Accounts Due to Subcontractors (a) Amounts Due Subcontractors ........................................................................................ $___________________ (b) Retained Percentage ...................................................................................................... $___________________ (c) Total Owing to Subcontractors ...................................................................................... $___________________

Designation of Contract and

Name of Subcontractor

Amount to Subcontract

Value of Work Done Based on Last Estimate

Approved

Percent

Retained

Amount Paid

to Date

Amount Due Subcontractor

Total

Schedule 16 - Accrued Taxes

Nature of Tax Payable To Date Payable For What Period Amounts

Schedule 17 - Other Current Liabilities

To Whom Nature Date Due Amounts

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Schedule 18 – Other Liabilities To Whom Nature Date Due Amounts

Schedule 19 – Individual or Partnership Capital

Name Address Amounts

Schedule 20 – Capital Stock

Authorized Unissued Treasury Stock Outstanding

Preferred Stock

Common Stock

$ $ $ $

Schedule 21 – Surplus or Retained Earnings

Earned Surplus ...................................................................................................................................................................

Capital Surplus ...................................................................................................................................................................

Explain Capital Surplus ...................................................................................................................................................... ________________________________________________________________________________________________________________________________________

TOTAL LIABILITIES & NET WORTH $....................................

If a corporation, answer this:

Total authorized capital ........................................................................................................................................

Capital paid ..........................................................................................................................................................

When incorporated .......................................................... In what state ................................................................

Officers (Name in Full) No. of Shares Held

Preferred Common Residence Address

President:

Vice President:

Secretary:

Treasurer:

Chairman of Bd. Of Directors:

Owner(s)\Percentage:

If a partnership, answer this: Name of Partners

Date of organization:

State whether co-partnership is general or limited:

If limited, explain fully:

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CONTINGENT LIABILITIES-Other Than Discounted Notes and Accounts Receivable 1. Liability as a Bondsman ................................................................................................... $___________________ 2. Liability as a Guarantor on Contracts, Notes or Accounts of Others .................................. $___________________ 3. Lawsuits Pending but not Reduced to Judgment ................................................................ $___________________ 4. Reserve for income tax liability. Applicable to Sub S Corporations, Partnerships, and Sole Proprietorships.............................................................................. $___________________ 5. Other Contingent Liabilities ............................................................................................. $___________________ Total ........... $___________________

CERTIFICATE OF PUBLIC ACCOUNTANT We have prepared the financial statement of _______________________________________________________ as of ____________________________, 20______. Our preparation was made in accordance with generally accepted auditing standards, and accordingly included such tests of the accounting records relating to the assets and liabilities and such other auditing procedure as we considered necessary in the circumstances. In our opinion, the accompanying financial statement presents fairly the financial position of ________________ _______________________________________ at ______________________________________________, 20_____, in conformity with generally accepted accounting principles. ________________________________________________ Certified Public Accountant Signed: _________________________________________ Certificate No. __________ State of __________________ Telephone No. ____________________________________ OR Signed: _________________________________________ Independent Licensed Public Accountant License No. ____________ State of __________________ Date: __________________________ Telephone No. ____________________________________ In lieu of the above certification, an Accountant's Certificate may be attached indicating the financial statement was prepared by the accountant, showing the scope of audit, and any procedure omitted which would normally be required in accordance with generally accepted auditing standards.

EXPERIENCE QUESTIONNAIRE The signing of this Questionnaire guarantees the truth and accuracy of all answers to interrogatories hereafter made. 1. How many years has your organization been in business as a contractor under your present business name? _________________________________ 2. How many years experience in _______________________________ construction work has your organization had as: (a) A prime contractor _________________________ (b) A subcontractor ____________________

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3. List major projects your organization has completed in the past 3 years. Use additional paper if necessary. Type of Work

Performed

Where Located

City, County, State

Year

Completed

Who, in #4B Below,

Was In Charge

Prime Contractor or Owner

Contract Amount

4. List ALL construction projects your organization has under way or in process of award: (Use additional paper if necessary.)

Project No. and

Owner

State and City or County

Who, in #4B Below,

Is In Charge

Amount of

Contract

%

Complete

% Time

Consumed

Type of Work

Performed 4.A. Describe the type or nature of work you performed with your own forces on the projects listed in 3 and 4 above. Indicate on which projects you were prime contractor. 4B. What is the construction experience of the principal individuals of your organization? Include resumes.

Individual's Name

Present Position

or Office

Years of Construction Experience

Age

Magnitude and Type of Work

In What Capacity

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5. If an applicant requests prequalification under any of the three bridge classifications shown on page iv, he must furnish evidence that his company did construct such a bridge or bridges. Information required consists of location, project number, owner, date of completion, name and telephone number of project engineer, contract amount, total length of bridge, length and number of spans, type of construction and other pertinent information. If applicant is prequalified for major bridge construction, he is considered qualified for intermediate and minor bridges. If qualified for inter- mediate bridge, he is also qualified for minor bridges. Failure to complete this item in detail will cause bridge classi- fication to be denied. Use additional paper if necessary. _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ 6. Give names and addresses of all banks with whom you have done business during the last three years, exclusive of those shown in Financial Statement.

Name of Bank

Location

Name and Address of Officers with Whom You Transacted Business

7. Give names and addresses of material or equipment houses with whom you have established a line of credit and purchased principal equipment and materials during the past three years.

Name of Firm or Company Address

8. List all persons and their titles who are authorized to sign bid documents, contracts, supplemental agreements, force accounts, and estimates:

Name

Title

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9. List surety companies with whom you have done business during the past 3 years.

Project No. County Owner Date of Contract

Date Accepted

Surety Company

10. Optional. Attach a copy of appraisal that is dated within 12 months of financial statement. This sheet must be completed before an appraisal is approved. See instructions on page i.

Asset Description*

Schedule 11 Book Value

Appraised Value

Appraisal in Excess of Book Values

Totals

*Asset numbers of book values must be Less 20% $___________________ cross referenced with appraised values. Increase in Asset Value $___________________

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AFFIDAVIT FOR INDIVIDUAL STATE OF __________________________________ 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 conditions as of the date thereof, and the answers to the interrogatories contained therein are true; that the statements and answers to the interrogatories of the foregoing plant and equipment questionnaire are correct and true as of the date of this affidavit; and, that the statements and answers to the interrogatories of the foregoing experience questionnaire are correct and true as of the date of this affidavit. ________________________________________________ (Applicant must also sign here) Sworn to and subscribed before me this _________ day of ___________________________________, 20_____. ___________________________________________ Notary Public

AFFIDAVIT FOR PARTNERSHIP AND LIMITED LIABILITY COMPANIES STATE OF _________________________________ COUNTY OF _______________________________ ___________________________________________, being duly sworn, deposes and says that he is a member of the firm of _________________________________________, and 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 hereof, and that the answers to the interrogatories contained therein are true; that the statements and answers to the interrogatories of the foregoing plant and equipment questionnaire are correct and true as of the date of this affidavit; and that the statements and answers to the interrogatories of the foregoing experience questionnaire are correct and true as of the date of this affidavit. ________________________________________________ (Member of firm must also sign here) Sworn to and subscribed before me this _________ day of _____________________________, 20_____. ___________________________________________ Notary Public

AFFIDAVIT FOR CORPORATION

STATE OF _________________________________ COUNTY OF _______________________________ ___________________________________________, being duly sworn, deposes and says that he is (title) ___________________________ of the ______________________________________, the corporation described in and which executed the foregoing statement; that he is familiar with the books of the said corporation showing its financial condition; that the foregoing financial statement, taken from the books of the said corporation, is a true and accurate statement of the financial condition of said corporation as of the date thereof, and that the answers to the interrogatories of the foregoing plant and equipment questionnaire are correct and true as of the date of this affidavit; and that the statements and answers to the interrogatories of the foregoing experience questionnaire are correct and true as of the date of this affidavit. ________________________________________________ (Officer must also sign here) Sworn to and subscribed before me this _________ day of _______________________________, 20_____. __________________________________________ Notary Public

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