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Form A-39

Appendix C


MTA Bridges and Tunnels

Triborough Bridge and Tunnel Authority

STATEMENT OF QUALIFICATION AND FINANCIAL CONDITION OF BIDDER





(To be submitted in duplicate)



The statements hereon are confidential and made solely for information in connection with the bid filed by



the undersigned on contract for..........................................................................................................



.........................................................................................................................................................

(Insert name of contract)



Statements must be made by a partner (if a co-partnership) or an officer (if a corporation) or his duly authorized representative, and must be sworn to.





GENERAL INFORMATION



1. Name of bidder .....................................................................................................................



2. Address (principal office) .........................................................................................................



Telephone No. ..............................................................................................



3. If a corporation: If a co-partnership:







Capital paid in cash, $.



Date of organization:



When incorporated



In what State



State whether partnership is general, limited or association






President's name:

Name and address of partners:






Vice-President's name:




Secretary's name:

.

..............................................



Treasurer's name: ...................................



...............................................






Note: (1) If a foreign corporation, attach proof of authority to transact business in State of New York.

(2) If a certificate of incorporation has not been previously filed with Triborough Bridge and Tunnel Authority, attached one certified copy.

4. Authorized capital stock $

Note: The amount of authorized capital stock issued and paid into the treasury of the corporation should be at least equal to the amount of free and liquid assets required by the contract.



5. Subscribed capital stock



Preferred $



Common $



6. Fully paid in capital stock



Preferred $



Common $



7. Who are the principal owners of capital stock, and approximately what percentage of the capital stock does each own?



NAME

ADDRESS

PER CENT OWNED



























BOND INFORMATION



8. Names and addresses of bonding company or companies that have agreed to furnish the performance bond required by the contract.





NAME

ADDRESS













FINANCIAL STATEMENT



Note: Statement should be as of a date not more than 30 days prior to the date of submission of this

Statement of Qualification and Financial Condition.



9. Following is a statement of financial condition at close of business 2005



ASSETS



1. Cash: (a) On hand $ (b) In banks $ (c) Elsewhere $

2. Notes receivable: (a) Due within 90 days

(b) Due after 90 days

(c) Past due

3. Accounts receivable from completed contracts, exclusive of claims not

approved for payment

4. 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

5. Amounts receivable from sources other than construction contracts

6. Deposits for bids or other guarantees: (a) Recoverable within 90 days

(b) Recoverable after 90 days

7. Interest accrued on loans, securities, etc

8. Real Estate:

(a) Used for business purposes

(b) Not used for business purposes

9. Stocks and bonds:

(a) Listed–present market value

(b) Unlisted–present value

10. Materials in stock not include in Item 4 (a) For uncompleted contracts

(present value)

(b) Other materials (present value)

11. Equipment, book value

12. Furniture and fixture, book value

13. Other assets

Total assets.

LIABILITIES

1. Notes payable: (a) To banks regular.

(b) To banks for certified checks.

(c) To others for equipment obligations

(d) To other exclusive of equipment obligations.

2.* Accounts payable: (a) Not past due

(b) Past due

3. Real estate encumbrances:

4. Other liabilities

5. Reserves

6. Capital stock paid up: (a) Common.

(b) Common

7. Surplus (net worth) Earned $. Unearned $

Total contingent liabilities

Dollars

Cts.

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. Other contingent liabilities

Total contingent liabilities



*Include all amounts owing subcontractors for all work in place and accepted on completed

and uncompleted contracts, including retainage.





DETAILS RELATIVE TO ASSETS



1

(a) on hand _____________________________________ $______________

Cash (b) deposited in banks named below __________________ ______________

(c) elsewhere—(state where) ________________________ ______________


NAME OF BANK

LOCATION

DEPOSIT IN NAME OF

AMOUNT























2*

(a) due within 90 days _____________________________ $______________

Cash (b) due after 90 days ______________________________ ______________

(c) past due_____________________________________ ______________


RECEIVABLES FROM: NAME AND ADDRESS

FOR WHAT

DATE OF

MATURITY

HOW SECURED

AMOUNT




























3*

Accounts receivable from completed contracts exclusive of claims not approved for payment _______________________________________ $_______________


NAME AND ADDRESS OF OWNER

NATURE OF

CONTRACT

AMOUNT OF CONTRACT

AMOUNT

RECEIVABLE























4*

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 contract _________$ _____________


NAME OF CONTRACT AND NAME AND ADDRESS OF OWNER

AMOUNT OF

CONTRACT

AMOUNT

EARNED

AMOUNT

RECEIVED

RETAINAGE


Amount Exclusive of Retainage





When

Due

Amount






























Have any of the above been assigned, sold or pledged?.....If so, state amount, to whom, and reason..............................

*List separately each item amounting to 10 per cent or more of the total and combine the remainder.



DETAILS RELATIVE TO ASSETS (Continued)



5*



Accounts receivable not from construction contracts _______________________ $ ______


Receivable From: NAME AND ADDRESS

FOR WHAT

WHEN DUE

AMOUNT

















What amount, if any, is past due $ ________________________________________ $ ______




6



Deposits with bids or otherwise as guarantees ______________________ $




DEPOSITED WITH: NAME AND ADDRESS



FOR WHAT

WHEN

RECOVERABLE



AMOUNT























7



Interest accrued on loans, securities, etc. _________________________$_____________


ONE WHAT ACCRUED

TO BE PAID WHEN

AMOUNT
















8

Real Estate (a) Used for business purposes ____________________________$_________

Book Value (b) Not Used for business purposes ________________________$_________




DESCRIPTION OF PROPERTY



IMPROVEMENTS

TOTAL

BOOK

VALUE


NATURE OF

IMPROVEMENTS

BOOKVALUE


1




2




3




4




Location

held in whose name

assessed value

amount of encumbrances

1




2




3




4




*List separately each item amounting to 10 per cent or more of the total and combine the remainder.



DETAILS RELATIVE TO ASSETS (Continued)



9

Stocks and Bonds: (a) Listed--present market value_________________ $_____________

(b) Unlimited —present value _________________________ $ _____________




DESCRIPTION

ISSUING COMPANY

LAST INTEREST OF DIVIDEND

PAID





PAR



PRESENT

MARKET











1



DATE

%

VALUE

VALUE

QUANTITY

AMOUNT

2









3









4









5










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






10

Materials in stock and not included in Item 4, Assets:

(a) For use on uncompleted contracts (present value) __________________ $__________

(b) Other materials (present value) ________________________________ $__________

DESCRIPTION OF MATERIAL

QUANTITY


PRESENT VALUE



FOR UNCOMPLETED CONTRACTS

OTHER MATERIALS



















11*



Equipment at book value ___________________________________________ $_____________




QUANTITY



DESCRIPTION AND CAPACITY OF ITEMS

AGE OF

ITEMS

PURCHASE PRICE

DEPRECIATION

CHARGED OFF

BOOK

VALUE







































Are they any liens against the above? ______________ If so, state total amount ______ $_________



*If two or more items are lumped above , give the sum of their ages.




DETAILS RELATIVE TO ASSETS (Continued)



12



Furniture and fixtures at book value _______________________________$___________






13



Other assets _______________________________________________$___________


Description

Amount









TOTAL ASSETS $_________



DETAILS RELATIVE TO LIABILITIES



1

(a) To banks, regular _____________________________ $__________

Notes Payable { (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 SECURITY

WHEN DUE

AMOUNT




















2

(a) Not past due _____________________________ $

Accounts Payable { (b) Past due _____________________________ $ ____________


TO WHOM: NAME AND ADDRESS

WHAT SECURITY

DATE PAYABLE

AMOUNT
















3



Real estate encumbrances (See Item 8, Assets) ___________________ $____________




4



Other liabilities _____________________________________________ $___________


Description

Amount







5

Reserves $ $ ________


INTEREST

INSURANCE

BLDGS. & FIXT.

PLANT DEPR.

TAXES


BAD DEBTS




$________

$________

$________

$________

$________

$________

$________

$________

$________












6

(a) Not past due ________________________ $____________

Capital stock paid up: { (b) Past due __________________________ $____________




7

Surplus: $ $ ________________




* Include all amounts owing subcontractors for all work in place and accepted on completed and uncompleted contracts, including retainage.



EXPERIENCE



10. How many years experience has present organization had:



As a contractor? ____________ As a subcontractor? _______________



11. Give briefly, previous construction experience of directing officers, including chief engineering and general superintendent.



NAME

PRESENT OFFICE

YEARS OF

CONSTRUCTION

EXPERIENCE


MAGNITUDE AND TYPE OF WORK

IN WHAT

CAPACITY






































12. List principal contracts completed by present organization.



LOCATION

CONTRACT

PRICE

CLASS OF

WORK


WHEN COMPLETED

NAME AND ADDRESS

OF AWARDING PARTY








































13. List contracts, if any, that present organization has on hand.



LOCATION

CONTRACT PRICE

CLASS OF

WORK


PERCENT

COMPLETED

NAME AND ADDRESS

OF AWARDING PARTY






































14. Given names and addressed for reference of at least two engineers or architects for whom present organization has done construction work.



NAME

ADDRESS

POSITION
























15. Has present organization ever failed to complete any work awarded to it? _________________

If so, give particulars ________________________________________________________

_______________________________________________________________________



PLANT



16. List principal items of available plant owned.





ITEM



NO.

DESCRIPTION, SIZE, CAPACITY, ETC.



CONDITION

YEARS OF SERVICE

PRESENT LOCATION







































17. List contracts, if any, that present organization has on hand.




ITEM


NO.


DESCRIPTION, SIZE, CAPACITY, ETC.


OWNED OR RENTED?





























SUBCONTRACTS



18. What parts of this contract, if any, does bidder expect to sublet?





PORTION OF WORK



NAME AND ADDRESS OF SUBCONTRACTOR















19. Give here any supplemental information that the bidder desires to submit.



_________________________________________________________________________________