STATE OF HAWAII

STANDARD

QUALIFICATION QUESTIONNAIRE

FOR

OFFERORS

issued by the

PROCUREMENT POLICY BOARD

STATE OF HAWAII

To be filed with the procurement 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 REQUIRE THE OFFEROR TO FURNISH ADDITIONAL INFORMATION NOT SPECIFICALLY COVERED HEREIN. ALL ITEMS MUST BE ANSWERED AND OMISSIONS MAY BE CONSIDERED GOOD CAUSE FOR UNFAVORABLE CONSIDERATION.

GENERAL INFORMATION

1. The statements contained in this Questionnaire are being furnished for consideration in submitting an offer for the following project:

(a)

(b)

(c)

2. The Questionnaire is being submitted in behalf of: A Corporation

(a)

An Individual

A Joint-Venture

(b)
(c)
(d)

3. If the bid is submitted by a joint venture, composed of two or more individual firms, then each member firm comprising the joint venture must submit all information listed on pages 3 through 16, inclusive, of the Questionnaire and, in addition, answer the following:

(a)
(b)
(c)

EXPERIENCE QUESTIONNAIRE

A Corporation

Submitted by __________________________________________ A Partnership

An Individual

Principal Office ____________________________________________

The signatory of this questionnaire guarantees the truth and accuracy of all statements and of all answers to interrogatories hereinafter made

1.
2.
3.

Contract Amt.

Class of Work

When Completed

Name and Address of Owner

4.
5.
6.
7.
8.
9.
10.
11.
12.

13.

Individual’s Name

Present Position or Office

Years of Work Experience

Magnitude and Type of Work

In What Capacity?

EQUIPMENT QUESTIONNAIRE

A Corporation

Submitted by __________________________________________ A Partnership

An Individual

Principal Office ____________________________________________

The signatory of this questionnaire guarantees the truth and accuracy of all statements and of all answers to interrogatories hereinafter made

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

Quantity

Item

Description, Size, Capacity, Etc.

Condition

Years of Service

Present Location

11.

Quantity

Item

Description, Size, Capacity, Etc.

Approximate Cost

12.

13.

FINANCIAL STATEMENT

A Corporation

Submitted by __________________________________________ A Partnership

An Individual

Principal Office ____________________________________________

The signatory of this questionnaire guarantees the truth and accuracy of all statements and of all answers to interrogatories hereinafter made

BALANCE SHEET

As of ________________________, 20______

Assets

Current assets:

Cash and cash equivalents (1) $ ________________

Short-term investments (2) ________________

Accounts receivable, net (3) ________________

Inventories (4) ________________

Costs and estimated earnings in excess of billings on uncompleted contracts (5) ________________

Prepaid expenses and other (6) ________________

Sub-Total Current Assets ________________

Property and equipment:

Land (7) ________________

Buildings (8) ________________

Vehicles, machinery and equipment (9) ________________

Furniture and fixtures (10) ________________

Less accumulated depreciation (_________________)

Sub-Total Net Property and Equipment ________________

Other assets:

Cash surrender value of life insurance policies (11) ________________

Deposits and other (12) ________________

Sub-Total Other Assets ________________

Total Assets: $

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 uncompleted 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 and Stockholder’s Equity $

DETAILS RELATIVE TO ASSETS

(1) Cash and cash equivalents:

Financial Institution Type of Account Amount

__________________________________________________________________________ $

__________________________________________________________________________

__________________________________________________________________________

$

(2)

Unrealized Unrealized Estimated

Type of Security Cost Gains Losses Fair Value

_ __ $ $ $ $ _

______ __ _ _ _ _

__________ __________ ___________ ___________

$ $ $ $

(3)

Completed contracts

Completion Contract Amount

Name Description Date Amount Receivable

_______ $ $ _ $

_______________________________________________ ___________ __________

_______________________________________________ ___________ __

$ $ $

Other than completed contracts

Amount

Name Description Due Date Receivable

__

__

_

Less allowance for doubtful accounts ( )

$

(4)

Lower of Cost

Description Cost Market Value or Market Value

$ $ $ ___

_ ______

______________________________________________ ___________ _

$ $ $

DETAILS RELATIVE TO ASSETS (Continued)

(5)

Costs and Costs and Estimated

Completion Contract Estimated Billings Earnings in

Name Description Date Amount Earnings to Date to Date Excess of Billings

______________________________________ $ _________ $ __________ $ _________ $ ___________

________________________________________ ___________ ___________ _________ ___________

________________________________________ ___________ ___________ _________ ___________

$ $ $ $

(6)

Description Amount

_________________________________________________________________________ $ _______________

_________________________________________________________________________

_________________________________________________________________________

$

(7)

Description Location Amount

_________________________________________________________________________ $

_________________________________________________________________________

_________________________________________________________________________

$

(8)

Description Location Amount

________________________________________________________________________ $

________________________________________________________________________

________________________________________________________________________

$

(9)

Description Amount

________________________________________________________________________ $

________________________________________________________________________

________________________________________________________________________

$

(10)

Description Amount

________________________________________________________________________ $

________________________________________________________________________

________________________________________________________________________

$

DETAILS RELATIVE TO ASSETS (Continued)

(11) Cash surrender value of life insurance policies

Paid-Up

Policy Additional CSV

Key Employee Insurance Company Amount Insurance Amount

________________________________________________ $ ____________ $ ____________ $__________

________________________________________________ ____________ _____________ ___________

________________________________________________ ____________ _____________ ___________

Less loans payable ____________ _____________ (__________)

$ $ $

(12) Deposits and other

Description Amount

__________________________________________________________________________ $ ______________

__________________________________________________________________________

__________________________________________________________________________

$

DETAILS RELATIVE TO LIABILITIES AND STOCKHOLDER’S EQUITY

(1) Current portion of long-term debt (maturing within 12 months)

Security

Lender Description Pledged Due Date Amount

_________________________________________________________________________ $ ______________

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

$

(2) Accounts payable (list major creditors)

Past Due

Name Amount Amount

_________________________________________________________ $______________ $

_________________________________________________________ _____________

_________________________________________________________ _____________

_________________________________________________________ _____________

$ $

(3) Billings in excess of costs and estimated earnings on uncompleted contracts

Costs and Billings in excess

Completion Contract Estimated Billings of costs and

Name Description Date Amount Earnings to Date to Date Estimated Earnings

_____________________________________________ $___________ $ ________ $_______ $ ___________

_____________________________________________ ___________ ________ _______ ____________

_____________________________________________ ___________ ________ _______ ____________

$ $ $ $

(4) Accrued liabilities and other

Description Amount

_________________________________________________________________________ $

_________________________________________________________________________

_______________________________________________________________________________________

$

(5) Long-term debt, net of current portion

Security

Lender Description Pledged Due Date Amount

________________________________________________________________________ $

________________________________________________________________________

________________________________________________________________________

$

DETAILS RELATIVE TO LIABILITIES AND STOCKHOLDER’S EQUITY (Continued)

(6)

No. of Shares

No. of Shares Issued and

Type of Stock Class Authorized Outstanding Par Value Amount

_______________________________________________________________ $ _____________$ __________

_______________________________________________________________ _____________ __________

_______________________________________________________________ _____________ __________

$

(7)

Description Amount

__________________________________________________________________________ $

__________________________________________________________________________

__________________________________________________________________________

$

(8)

No. of

Type of Stock Class Shares Cost

__________________________________________________________________________ $

__________________________________________________________________________

__________________________________________________________________________

$

STATEMENTS OF INCOME AND RETAINED EARNINGS

For the Years Ended ________________________, 20____ and 20 ____

20____ 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 income

Retained earnings, beginning of the year

____________

___________

Retained earnings, end of the year

$

$

If a corporation, answer this:

Capital paid in cash, $ _______________________________

When Incorporated __________________________________

In what State _______________________________________

Date registered in Hawaii ____________________________

President's name ___________________________________

Vice-President's name _______________________________

Secretary's name ___________________________________

Treasurer's name ___________________________________

If a partnership, answer this:

Date of organization ___________________________________

Date registered in Hawaii ________________________________

State whether partnership is general or limited ______________

______________________________________________________

Name and address of partners:

_________________________________________

_________________________________________

_________________________________________

Age

________

________

________

The undersigned 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 purpose of inducing the party to whom it is submitted to award the offeror 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 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 and that the answers to the foregoing interrogatories are true.

___________________________________________

Sworn to before me this (Applicant must also sign here)

____________________ day of _______________ 20_____

_________________________________________________

Notary Public

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 of the said firm, is a true and accurate statement of the financial condition of the said firm as of the date 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

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 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 foregoing interrogatories are true.

_____________________________________________

Sworn to before me this (Officer must also sign here)

____________________ day of ___________________ 20_____

_______________________________________________

Notary Public