CONTRACTOR QUALIFICATIONS STATEMENT

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1 Page 1 of 6 CONTRACTOR QUALIFICATIONS STATEMENT The undersigned certifies under oath the truth and correctness of all statements and of all answers to questions made hereinafter. SUBMITTED TO: St. Vrain Sanitation District, Firestone, Colorado SUBMITTED BY: CHECK ONE: Corporation Partnership Individual Joint Venture Other 1. How many years has your organization been in business as a General or? 2. How many years has your organization been in business under its present business name? 3. If a Corporation, answer the following: a. Date of Incorporation b. State of Incorporation c. President d. Vice President(s) e. Secretary f. Treasurer 4. If a Partnership, answer the following: a. Date of Organization b. Type of Partnership c. Name and Address of all partners:

2 Page 2 of 6 5. If other than a Corporation or Partnership, describe the organization and name principals: 6. What percent of work do you normally perform with your own forces: % List Self-performed Trades: 7. Have you ever failed to complete any work awarded to you? If so, indicate when, where and why. 8. Has any officer or partner of your organization ever been an officer or partner of another organization that failed to complete a construction contract? If so, what were the circumstances?.

3 Page 3 of 6 9. List major construction projects your organization has under contract as of this date. Add additional pages as necessary to list projects. Project Name Owner Architect/ Engineer Amount Date Percent Complete Scheduled Completion 10. List major construction projects your organization has completed in the past 5 years; add additional pages as necessary to list projects. Change Order Summaries may be attached as separate pages, and are to be clearly marked with Project Name & Owner. Final Amount Project Name Owner Architect/ Engineer Original Amount w/change Order Summary Scheduled Completion/ Date Achieved % of Own Forces

4 Page 4 of List the construction experience of the principal individuals in your organization: Individual s Name Construction Experience (years) Present Position & Years Experience Dollar Volume Responsibility Previous Position & Years Experience 12. List states and categories in which your organization is legally qualified to do business: 13. Credit references: 14. Trade references:

5 Page 5 of Name of bonding and insurance companies, and name and address of agents. Provide a letter from a surety included on the United States Treasury list of acceptable surety corporations expressing the capacity to bond this Project. Maximum Bonding Name of Company Name of Agent Address of Agent Capacity 16. The undersigned agrees to furnish, within 24 hours upon request by the Owner, a current Statement of Financial Conditions, including the or s latest regular dated financial statement of balance sheet which must contain the following items: Current assets: Current liabilities: Cash, joint venture accounts, accounts receivable, notes receivable, accrued interest on notes, deposits, and materials, and prepaid expenses, next fixed assets and other assets. Accounts payable, notes payable, accrued interest on notes, provision for income taxes, advances received from owners, accrued salaries, accrued payroll taxes, other liabilities, and capital (capital stock, authorized and outstanding shares par values, earned surplus). Date of statement of balance sheet: Name of firm preparing statement: By (Agent and Capacity): 17. Dated at, this (Day) day of. (Year) Name of Organization: By: Title:

6 Page 6 of NOTARIZATION: State of: County of: M being duly sworn deposes and say that (he/she) is the of or(s) and that the answers to the foregoing questions and all statements therein contained are true and correct. Subscribed and sworn before me this (Day) day of. (Year) Notary Public: My commission expires:

The Undersigned certifies under oath that the information provided herein is true and sufficiently complete so as not to be misleading.

The Undersigned certifies under oath that the information provided herein is true and sufficiently complete so as not to be misleading. The Undersigned certifies under oath that the information provided herein is true and sufficiently complete so as not to be misleading.! " " [] Corporation [] Partnership [] Individual [] Joint Venture

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