RETURN THIS FORM WITHA COPY OF YOUR MOST

RECENT AUDITED FINANCIAL STATEMENT

INCLUDING AUDITOR'S NOTES

JOHN W. HUGHES, P. E.

DIRECTOR OF ENGINEERING

PORT OF INDIANA, BURNS HARBOR/PORTAGE

6625 SOUTH BOUNDARY ROAD

PORTAGE, INDIANA 46368

CONFIDENTIAL EXPERIENCE DATA AND FINANCIAL STATEMENT

FOR

PREQUALIFICATION OF CONTRACTORS

AND

SUBCONTRACTORS

SUBMITTED BY:

A. CONFIDENTIAL BIDDERS QUALIFICATION DATA

DATE:

1. Name of Contractor or Sub-Contractor

2. Home Office Address

3. Home Office, Telephone

4. Type of Organization (Check One)

Individual Partnership Corporation

General Co-Partnership Limited Co-Partnership Other

If Other, Explain

5. Branch Offices

Address and Telephone Person in Charge

Geographical Radius of operation in miles

Contractors and Sub-Contractors not incorporated in the State of Indiana must submit with this

form a certificate from the Secretary of State which authorizes them to do business in Indiana.

6. List all active partners and/or principal officers of firm.

Name and Title Address Fractional Interest

7. List other businesses, related to construction, in which any officer or partner is engaged.

Partner or Officer Name of Other Company Extent of Interest

8. Type of construction work performed (check ones which apply).

General Construction Plumbing Electrical

Excavating Paving Pipe Covering

Concrete Masonry Roof Deck

Sheet Metal Glazing Acoustical

Marble Painting Temperature Control

Landscaping Heating Ventilation & Air Conditioning

Demolition Grading Structural Steel

Reinforcing Steel Roofing Insulation

Windows Lathing & Plastering Ceramic Tile & Terrazzo

Millwork Hardware Fire Protection

Kitchen Equipment Other

If Other, Explain:

9. List the key construction personnel, their ages, positions held and years of construction

experience.

Years of

Construction

Name and Age Present Position Experience

10. List recently completed contracts performed (at least five within the last five years) including

the owner or contractor, class of work, date completed and contract amount.

Class of Date Contract

Owner Work Completed Amount

11. List project presently under contract including owner or contractor, class of work, date

awarded and contract amount.

Class of Date to be Contract

Owner Work Completed Amount

12. List, the references, Architect, Engineer, or Architect-Engineer for recently completed

contracts.

Architect, Engineer or Architect-Engineer

Project (Show Complete Address)

A.

B.

C.

D.

E.

F.

13. Have you previously performed work for the Indiana Port Commission?

Yes No If yes, list most recent project

14. Give the average dollar volume of work that your organization has performed for the last five

years.

15. Give the average number of employees on your payroll for the last two years.

16. How many years has your organization been in business as a contractor or sub-contractor?

years.

17. How many years has your organization been in business under the present name?

years.

18. Give a brief history of your organization.

If a Corporation, answer questions 19 through 23.

19. Capital paid in-cash $

20. When Incorporated?

21. In what state?

22. Is the corporation in good standing with the Secretary of State, State of Indiana?

Yes No

23. If an out-of State Corporation, give date of authorization to do business in the State of

Indiana

Note: Out-of-State Corporation must attach hereto a copy of certificate from the

Secretary of State, State of Indiana for verification of the authorization to transact

business in the State of Indiana.

If a Co-Partnership, answer questions 24 through 25.

24. Date of Organization?

25. State which partners are other than general partners, giving names and addresses.

Note: If joint statement, prepared and executed as a co-partnership or corporation and

submit under the name in which the combination will expect to do business and execute

contracts. On separate sheets supply the organization data as above for each participating

co-partnership or corporation. The co-partnership affidavit on Page 16 is to be executed

by a person with authority to represent the combination and affirmed by all other

participants including all general partners of any participating co-partnership.

26. Have you ever failed to complete any work awarded to you?

If so, where and why?

Has any officer or partner of your organization ever been an officer or partner of some other

organization that failed to complete a construction contract?

If so, state name of individual, other organization and the reason therefor

28. Has any officer or partner of your organization ever failed to complete a construction

contract handled in his own name?

If so, state name of individual, name of owner and reason therefor

29. For what corporations or individuals have you performed work and to whom do you refer?

30. For what cities have you performed work and to whom do you refer?

31. For what counties have you performed work and to whom do you refer?

32. For what state bureaus or departments have you performed work and to whom do you refer?

33. Have you ever performed any work for the U. S. Government?

If so, when and to whom do you refer?

34. What percentage of the construction work is performed by your own forces?

% Minimum % Maximum

35. Have you been in dispute or litigation with the State of Indiana?

Yes No

If yes, give the details

36. Have you been prequalified in any other state?

If yes, give state

Construction Equipment:

(a) Construction equipment and attachments – Book Value $

(b) Office furniture and equipment – Book Value $

Description (Kind, Capacity, Mfgr., etc.)

Years old

Years Owned

If rebuilt by Mfgr., give date

Cost When New (Est. if purchased 2nd hand)

Cost Second hand if so purchased

Depreciation charged off

Book Value

Encumbrance

Statement of Assets and Liabilities as of , 20 .

Calendar dates of Fiscal year from to .

ASSETS

CURRENT ASSETS

1. Cash:

(A.) On Hand $

(B.) Name of Bank

(C.) In Bank $

2. Bid deposits and Guarantees $

3. Accounts receivable from construction contract.

(A.) Completed contracts $ $

(B.) Earned estimates on uncompleted contracts $

(C.) Retainage due to date upon completion of contracts $

(D.) Retainage due on approved completed contracts and final estimate due on

completed contracts $

4. Accounts receivable from sources other than completed contracts $

5. Interest accrued on loans, securities, etc. $

6. Marketable securities $

(A.) Listed-present market value $

(B.) Unlisted-present value (declarer should substance) $

7. Materials and supplies in stock not included in items 3B and

3C above $

8. Other current assets $

TOTAL CURRENT ASSETS $

FIXED AND OTHER ASSETS

9. Notes receivable

(A.) Due Within 90 days

(B.) Due after 90 days

(C.) Past due

10. Real Estate

(D.) Used for business

(E.) Not used for business

11. Construction equipment-net book value

12. Furniture and fixtures-net book value

13. Other assets

TOTAL FIXED AND OTHER ASSETS

TOTAL ASSETS

LIABILITIES AND NET WORTH

CURRENT LIABILITIES

14. Notes payable

(A.) Banks-exclusive of equipment obligations

(B.) Equipment obligations

(C.) Material suppliers

(D.) Others

15. Accounts payable

(A.) To sub-contractors (Estimates and Retainage)

(B.) Material suppliers

(C.) Others

16. Accrued taxes and expenses

(A.) Federal Income Tax

(B.) Withholding Tax

(C.) Gross Income Tax

(D.) Payroll

(E.) Interest

(F.) Other

17. Real Estate encumbrances due within one year

TOTAL CURRENT LIABILITIES

18. Long term liabilities

(A.) Real Estate Mortgates due after one year

(B.) Equipment notes due after one year

19. Other liabilities

20. Net worth

(A.) Capital stock

(B.) Reserves

(C.) Retained earnings

(D.) Capital Account: (Partnership or Individual)

SUB-TOTAL, NETWORTH

TOTAL LIABILITIES & NET WORTH

21. Contingent liabilities

AUDITORS REPORT

have examined the balance sheet of as of

, 20 , in accordance with generally accepted auditing standards

and accordingly includes such tests of the accounting records and such other auditing procedures

as considered necessary in the circumstances.

In opinion, the accompanying balance sheet presents

fairly the financial position of

at 20 , in conformity with generally accepted accounting

principles applied on a basis consistent with that of the preceding year.

Name, address and phone number of

**Accounting Firm:

Signed by

Date

The Indiana Port Commission of the State of Indiana is hereby authorized to obtain all additional

information which it deems necessary and pertinent to amplify the information given herein,

including the inquiries of hanks, other financial institutions, surety companies, clients, dealers in

materials, sub transaction with our organization.

Name of Organization, Partnership, Corporation or Individual.

By:

Date:

**”Financial Statements shall be prepared and certified by an Independent Certified Public

accountant holding an unrevoked certificate in any State or shall be prepared an attested as

correct by either a registered, licensed or certified public accountant holding a valid permit to

practice accountancy under applicable Indiana law.”

CORPORATE SEAL

IF

CORPORATION

AFFIDAVIT FOR INDIVIDUAL

State of

ss:

County of

, being duly sworn, deposes and says: That he is the

person submitting the foregoing statement of experience and financial position; that he has read

the same and that, inducing the Indiana Port Commission to award the submitter a contract and

that any depository, vendor, or other agency therein named or with whom he has had business

relations is hereby authorized to supply the said Commission with any information necessary to

verify the statement.

Applicant must sign here

Sworn to before me this day of , 20 .

Notary Public

AFFIDAVIT FOR CO-PARTNERSHIP

State of

ss:

County of

, being duly sworn, deposes and says: That he is a

partner of the partnership of , that said partnership is

submitting the foregoing statement of experience and financial position; that he had read the

same and that the same is true of his own knowledge; that the statement is for the purpose of

inducing the Indiana Port-Commission to award the submitter a contract and that any depository,

vendor, or other agency therein named or supply the said Commission with any information

necessary to verify the statement.

Member of firm must sign here

Sworn to before me this day of , 20 .

Notary Public

The foregoing statement and affidavit are hereby affirmed:

REMAINING MEMBERS OF FIRM MUST SIGN HERE

AFFIDAVIT FOR CORPORATION

State of

ss:

County of

, being duly sworn, deposes and says:

That he is _________________________________________, of _____________________

____________________________________________, the corporation submitting the foregoing

statement of experience and financial position; that he has read the same and that the same is true

of his own knowledge; that the statement is for the purpose of inducing the Indiana Port

Commission to award the submitter a contract and that any depository, vendor, or other agency

therein named or with whom it has had business relations is hereby authorized to supply the said

Commission with any information necessary to verify the statement.

Officer must sign here

Sworn to before me this _____ day of , 20 .

Notary Public

AFFIX CORPORATE SEAL