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

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.

(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.

_________________________________________________________________________________