RD2.10 CONTRACTOR'S STATEMENT OF EXPERIENCE AND FINANCIAL CONDITION
(see [I]:4.4.2 and [I]:8.5.3)

UNIVERSITY OF CALIFORNIA

CONTRACTOR'S STATEMENT OF EXPERIENCE AND FINANCIAL CONDITION

Submitted by:

Name of firm: _________________________________________

Address: _________________________________________

City, State, Zip Code: _________________________________________

Telephone: _________________________________________

Date: ______________

STATEMENT OF EXPERIENCE

Submitted By ______Corporation ______Partnership ______Individual ______ Joint Venture
(Name must correspond with Contractor's License in every detail)

If a corporation, organized under the laws of what state? _________________________
Address of Principal Office ______________________________________________________________

The signatory of this Statement guarantees the truth and accuracy of all statements and of answers to all questions hereinafter made. Failure to complete and return this Statement, or any false statement therein may render a bid non-responsive at the sole discretion of the University.

  1. Is your organization licensed as a Contractor to do business in California?
    Yes ( ) No ( )
    License No.______Type ______Exp. Date ______
    Classification of Specialty Contractor ______

  2. How many years has your organization been in business under its present business name? ______

  3. How many years experience in construction work has your organization had:
    (a) as a General Contractor? ______ (b) as a Subcontractor? ______

  4. Separately list (1) the projects your organization has completed within the past five years and (2) all University projects on which you worked during the past ten years, providing the following information for both lists of projects:

    Type______For Whom Performed ______ Year of Work______ Contract Amount ______
    Location of Work______ (Name and Telephone No.) ______

    (expand this list as required)

  5. Have you or your organization, or any officer or partner thereof, failed to complete a Contract?
    Yes ( ) No ( ) If yes, give details including dates.
    _______________________________________________________________________________
    _______________________________________________________________________________

  6. Has your organization ever been assessed liquidated damages for failing to complete a Contract within the time specified in the Contract Documents? Yes ( ) No ( ) If yes, give details.
    _______________________________________________________________________________
    _______________________________________________________________________________

  7. In what other lines of business do you or your organization or any partner thereof have financial interest?
    _______________________________________________________________________________
    _______________________________________________________________________________

  8. For what corporations, individuals, cities, counties, or state or governmental bureaus have you performed work? Please provide references from each entity that is familiar with your work and list their current telephone numbers.
    _______________________________________________________________________________
    _______________________________________________________________________________

  9. Name the persons with whom you have been associated in business as partners or business associates during the past five years.
    _______________________________________________________________________________
    _______________________________________________________________________________

  10. Describe the construction experience of the principal individuals in your organization by furnishing the following information:

    Individual's Name Present Position
    or Office Held in
    Your Organization     		Years of
    Construction
    Experience     		Magnitude and
    Type of Work     		In What
    Capacity?

    (expand this list as required)

    If a corporation, provide the following information:

    Date of incorporation_______________________________________
    In what state _______________________________________
    President's name _______________________________________
    Vice President's name _______________________________________
    Secretary's name _______________________________________
    Treasurer's name _______________________________________

    If a partnership, provide the following information:

    Date of organization _______________________________________
    State whether partnership is general or association______________________________
    Name and address of each general partner _______________________________________

STATEMENT OF FINANCIAL CONDITION

Banker _____________________________________________________________________
(Name, address, and telephone number)
_____________________________________________________________________

Surety Company _____________________________________________________________________
(Name, address, and telephone number)
_____________________________________________________________________

Financial condition at close of business on ______________, 19___
_____________________________________________________________________
_____________________________________________________________________

ASSETS - Please provide a detail total

Current Assets

  1. Cash
  2. Notes receivable
  3. Accounts receivable from completed contracts
  4. Sums earned on incomplete contracts
  5. Other accounts receivable
  6. Advances to construction joint ventures
  7. Materials in stock not included in Item 4
  8. Negotiable securities
  9. Other current assets

Total

Fixed and Other Assets

  1. Real Estate
  2. Construction plant and equipment
  3. Furniture and fixtures
  4. Investments of a non-current nature
  5. Other non-current assets

Total
Total Assets

LIABILITIES AND CAPITAL

Current Liabilities

  1. Current portion of notes payable, exclusive of equipment obligations and real estate encumbrances
  2. Accounts payable
  3. Other current liabilities

Total

Other Liabilities and Reserves

  1. Real estate encumbrances
  2. Equipment obligations secured by equipment
  3. Other non-current liabilities and non-current notes payable
  4. Reserves

Total

Capital and Surplus

  1. Capital Stock Paid Up
  2. Surplus (or Net Worth)

Total Total Liabilities and Capital

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 contractor on accounts of others
  5. Other contingent liabilities

Total Contingent Liabilities

Notes:

  1. Enter sums for numbered items 1 through 28 in shaded spaces in Detail column. Then enter total sums of main headings in shaded spaces in Total column.
  2. A copy of the accountant's opinion or report must be attached to the Statement of Financial Condition. See Instruction 7 on page 2. Acceptable forms are contained therein.

DECLARATION

(For Individual, Partnership, or Corporation)

_______________________________________________________________________________
Name (name of Individual, Partner, or Officer)

(If an individual, doing business as ________________________________________________________________) declares: That I am (capacity) of the (entity) submitting the Contractor's Statement of Experience and Financial Condition; that I have read the Statement of Experience and all of the information furnished in it is true, and correct of my own knowledge; that I have read the Statement of Financial Condition and am familiar with the accounting records from which it was prepared; and that the Statement of Financial Condition is a true and accurate statement of (my or the) financial condition (of the partnership or firm) as of its date (any other representations deemed appropriate).

I declare under penalty of perjury that the foregoing is true and correct and that this declaration was subscribed at:

________________, (City) ______________,(County) State of ___________________

on ______________________, 19________.

_______________________________________

(Individual, Partner, or Officer must sign here)

For partnership only:

The foregoing declaration is hereby affirmed
_______________________________________________________________________________
_______________________________________________________________________________
(Remaining Partners of firm sign here)

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