CS-4300 (11-99) Part 1

COMMONWEALTH OF PENNSYLVANIA

DEPARTMENT OF TRANSPORTATION

HARRISBURG, PENNSYLVANIA

CONFIDENTIAL

PART 1

CONTRACTOR’S FINANCIAL STATEMENT

NOTE: All requested information must be submitted in the format displayed on this form. The Department

will not accept any substitute submission of the requested information. This form must be completed

in total.

Contractor A Corporation

Business Address

Street P.O. Box No. State of Incorporation

A Co-Partnership

City State Zip Code

An Individual

Telephone Number ( ) ______Fax Number ( )______Affiliate/Subsidiary/

Division

Prequalification Number ______

Business Partner Registration Number

Date Submitted

FOR DEPARTMENT USE ONLY:

Financial Statement

Examined/Accepted By:

Accountant Date

CS-4300 (11-99) Part 1

REVIEWED FINANCIAL STATEMENT

Section 457.4(b) of the Prequalification Regulations allows for the acceptance of a Reviewed Financial Statement under certain conditions. In order to provide clarification as to how the Department intends to implement this provision of the Prequalification Regulations, the following information is provided:

¨  A review statement will be accepted if the net working capital, as determined by the Comptroller’s Office,

¨  is less than $50,000.

¨  A review statement will not be accepted if the net working capital, as determined by the Comptroller’s Office, is negative.

¨  A review statement will not be accepted if the Maximum Capacity Rating (Q) as calculated in Section 457.5(f) exceeds four million dollars ($4,000,000.00).

¨  If a Review Statement is not acceptable, you will be informed in writing by the Department that one of the following options is available for consideration:

(a)  A current audited financial statement may be submitted for the Department’s evaluation.

(b)  Prequalification as a subcontractor may be requested as noted in Section 457.4(a)(5). Submission of Part 1, Financial Statement, is not required for subcontractor approval.

¨  An Accountant’s Certificate to accommodate a Review Statement has been inserted for your use, if necessary, following this sheet.


ACCOUNTANTS CERTIFICATE

I (We) have reviewed the accompany balance sheet and related financial statement of ______for the period ended ______, in accordance with standards established by the American Institute of Certified Public Accountants. All information included in these financial statements is the representation of the management of the company.

A review consists principally of inquiries of company personnel and analytical procedures applied to financial data. It is substantially less in scope than an examination in accordance with generally accepted auditing standards, the objective of which is the expression of an opinion regarding the financial statements taken as a whole. Accordingly, we do not express such an opinion.

Based on our review, we are not aware of any material modifications that should be made to the accompanying financial statements in order for them to be in conformity with generally accepted accounting principles.

Registration Number ______Signed ______

Name of Certified Public Accountant/Public Accountant

______

Accounting Firm Name

Authorized to do business in ______

State

______

Address

Part 1, Page 3

CS-4300 (11-99) Part 1

ACCOUNTANTS CERTIFICATE

______

Date

I (We) have audited the balance sheet and related financial statements of ______for the period ended ______. These statements are the responsibility of the company’s management. Our responsibility is to express an opinion on these statements based on our audits.

We conducted our audits in accordance with generally accepted auditing standards. Those standards require that we plan and perform the audit to obtain reasonable assurance whether the financial statements are free of material misstatement. Our audit included examining, on a test basis, evidence supporting the amounts and disclosures in the financial statements. Our audit also included assessing the accounting principles used and significant estimates made by management, as well as evaluating the overall financial statement presentation. Any lines of credit extended by banks were also verified. We believe that our audits provide a reasonable basis for our opinion.

In our opinion, the financial statements referred to above present fairly, in all material respects, the financial position of______as of ______, in conformity with generally accepted accounting principles.

Registration Number ______Signed______

Name of Certified Public Accountant/Public Accountant

______

Accounting Firm Name

Authorized to do business in ______

State

______

Address

Part 1, Page 4

CS-4300 (11-99) Part 1

BALANCE SHEET [see pg. 7]

as of A Corporation

Submitted by ______A Co-Partnership

Date An Individual

ASSETS / ADJUSTED
WORKING
CAPITAL
[see pg.7-(b)]
A. CASH ______$______
1. On Hand ______$______/ $______
2. In Banks (Unrestricted) ______/ ______
3. Elsewhere (Unrestricted) ______/ ______
4. Other ______
B. BID DEPOSITS, GUARANTIES______$______/ ______
C. ACCOUNTS RECEIVABLE (Less Related Reserves) ______$______
1. Completed Contracts (Exclude Claims not yet Approved) ______$______/ ______
2. Uncompleted Contracts (Monthly Estimates Exclusive of Retainage) ______/ ______
3. Affiliated Companies (Due within one year) ______/ ______
4. Other______
D.  NOTES AND ACCEPTANCES RECEIVABLE ______$______
1. Trade (Portion due within one year) ______$______/ ______
2. Affiliated Companies (Due within one year) ______/ ______
3. Other ______
E.  INVESTMENTS ______$______
1. Listed Stocks and Bonds [see pg.7-(c )] ______$______/ ______
2. Unlisted Stocks and Bonds (Exclude stock in Affiliated Companies) [see pg.7-(d)] ______/ ______
3. Joint Ventures [see pg.7-(e)] ______/ ______
4. Other ______
F. INVENTORIES ______$______
1. Materials, Supplies, Stock Available for Contracts or Sale ______$______/ ______
2. Other ______
G. ACCRUED INCOME ______$______
1. Work in Progress – Unbilled (Include Retainage) ______$______/ ______
2. Other ______
H. PREPAID EXPENSES ______$______/ ______
I. PLANT PROPERTY (Less Reserve for Depreciation) ______$ ______
1. Machinery and Equipment (Used in Operation of Business) ______$______
2. Land and Buildings (Used in Operation of Business) ______
3. Furniture and Fixtures ______
J. OTHER ASSETS ______$ ______
1. Land and Buildings – Not Used in Operation of Business ______
2. Other ______
TOTAL ASSETS ______$______/ $______

Part 1, Page 5

CS-4300 (11-99) Part 1

Part 1, page 6

CS-4300 (11-99) Part 1

BALANCE SHEET (continued)

LIABILITIES AND NET WORTH
LIABILITIES:
K.  NOTES PAYABLE ______$______
1.  Banks, Trade, Sundry (Due within one year) ______$______
2.  Affiliated Companies (Due within one year) ______
3.  Other ______
L.  ACCOUNTS PAYABLE ______$______
1.  Payable to Subcontractors ______$______
2.  Trade ______$______
3.  Affiliated Companies ______$______
4.  Other ______$______
M.  ACCRUED TAXES ______$______
1.  Income ______$______
2.  Other ______$______
N.  ACCRUED SALARIES, WAGES AND OTHER EXPENSES ______$______
O. MORTGAGES AND BONDS PAYABLE ______$______
1.  Due within one year ______$______
2.  Other ______$______
P.  OTHER LIABILITIES ______$______
TOTAL LIABILITIES ______$______
NET WORTH:
Q.  INDIVIDUAL OR PARTNERSHIP CAPITAL ______$______
R. CAPITAL STOCK: ______$______
1.  Common ______$______
2.  Preferred ______$______
S.  SURPLUS ______$______
1.  Appropriated ______$______
2.  Unappropriated ______$______
3.  Paid-In ______$______
T.  TOTAL CAPITAL AND SURPLUS ______$______
1.  Less: Treasury Stock ______$______
TOTAL NET WORTH ______$______
TOTAL LIABILITIES AND NET WORTH ______$______/ ADJUSTED
WORKING

CAPITAL

$______
______
$______
______
______
$______
______
$______
$______
$______

Part 1, page 6

CS-4300 (11-99) Part 1

BALANCE SHEET OF ______as of ______

CONTINGENT LIABILITIES:

Liability on notes receivable discounted or sold $______

Liability on accounts receivable pledged, assigned or sold ______

Liability as bondsman ______

Liability as guarantor on contracts or on accounts of others ______

Liability under any judgements, suits or claims pending against you or any member of your firm ______

Other contingent liabilities (itemize) ______

Total $______

Instructions For Balance Sheet:

(a)  The Balance Sheet shall reflect financial condition in accordance with generally accepted accounting principles.

(b)  The contractor shall enter applicable amounts on all the lines provided. The Pennsylvania Department of Transportation shall review items excluded from the Adjusted Working Capital column and determine the propriety of any further inclusions. The Department reserves the right of final determination of all items and may make verification thereof to the extent deemed necessary.

(c)  Use market value rather than cost for listed stocks and bonds.

(d)  Use of the lower of cost or market for unlisted stocks and bonds.

(e)  That share of Adjusted Working Capital of the joint venture, which is attributable to the contractor being evaluated. Furnish supporting data.

(f)  If more space is required for data on supporting schedules, attach additional sheets.

Part 1, page 7

CS-4300 (11-99) Part 1

DETAILS RELATIVE TO ASSETS

SCHEDULE A – CASH

BALANCE SHEET ITEM / NAME AND LOCATION OF BANK OR OTHER DEPOSITORY / DEPOSITED IN NAME OF / AMOUNT /
$
TOTAL / $
Indicate how much is restricted as to use for purposes other than current operations. Describe – / $

SCHEDULE B – BID DEPOSITS, GUARANTIES

BALANCE SHEET ITEM / DEPOSITED WITH: NAME AND ADDRESS / PURPOSE OF DEPOSIT / DATE DEPOSITED / DATE RECOVERABLE / AMOUNT /
$
TOTAL / $

2

Part 1, Page 8

CS-4300 (11-99) Part 1

Part 1, page 6

CS-4300 (11-99) Part 1

SCHEDULE C – ACCOUNTS RECEIVABLE

PART 1 Accounts Receivable from completed contracts exclusive of claims not yet approved for payments:

BALANCE SHEET ITEMS / DESIGNATION OF CONTRACT NAME AND ADDRESS OF OWNER / AMOUNT OF CONTRACT / AMOUNT RECEIVABLE / WHEN DUE /
$ / $
TOTAL / $
Have any of the above been assigned, sold or pledged? ______If so, state amount , to whom, and reason ______

SCHEDULE C – ACCOUNTS RECEIVABLE

Accounts Receivable from uncompleted contracts:

Amount Due on monthly estimates exclusive of retainage (Col. 4) $ ______

PART 2 Note: Transfer Total from Col. 5 to Schedule G – Accrued Income

BALANCE SHEET ITEM / DESIGNATION OF CONTRACT AND NAME AND ADDRESS OF OWNER / AMOUNT OF CONTRACT
(1) / TOTAL AMOUNT EARNED AS OF BALANCE SHEET DATE
(2) / CASH PREVIOUSLY RECEIVED
(3) / Amounts Due on Outstanding Monthly Estimates Exclusive of Retainage
(4) / Unbilled Balance of Total Earned Including Retainage Due*
(5) /
$ / $ / $ / $ / $
TOTAL / $ / $ / $ / $
Have any of the above been assigned, sold or pledged? ______If so, state amount, to whom, and reason ______

*”Retainage Due” includes Securities held in lieu of retainage

Part 1, page 9

CS-4300 (11-99) Part 1


SCHEDULE C – ACCOUNTS RECEIVABLE (cont’d)

PART 3 Accounts receivable from other than construction contracts:

BALANCE SHEET ITEM / RECEIVABLE FROM: NAME AND ADDRESS / DESCRIPTION / WHEN DUE / AMOUNT /
$
TOTAL / $
Have any of the above been assigned, sold or pledged? ______If so, state amount , to whom, and reason ______

SCHEDULE D – NOTES AND ACCEPTANCES RECEIVABLE

BALANCE SHEET ITEM / RECEIVABLE FROM: NAME AND ADDRESS / DATE OF MATURITY / HOW SECURED / FACE VALUE /
$
TOTAL / $

Indicate your contingent liability for discounted notes and acceptances receivable:

WITH WHOM DISCOUNTED – ADDRESS / MAKER OF NOTE / DATE OF MATURITY / FACE VALUE /
$

Part 1, Page 10

CS-4300 (11-99) Part 1

SCHEDULE E – INVESTMENT

PART 1 STOCKS AND BONDS (Do Not Include Securities Deposited With State Treasurer in Lieu of Retainage)

*Indicate by asterisk stocks and bonds which are unlisted

BALANCE SHEET ITEM / DESCRIPTION / NAME AND ADDRESS OF ISSUING COMPANY / QUANTITY / PRESENT MARKET VALUE / COST
(BOOK VALUE) / AMOUNT PLEDGED OR IN ESCROW /
$ / $ / $
TOTAL / $ / $ / $

If pledged or in Escrow, state for whom and reason:

SCHEDULE E – INVESTMENTS

PART 2 – JOINT VENTURES FURNISH BALANCE SHEET OR STATEMENT OF WORKING CAPITAL FOR JOINT VENTURES

BALANCE SHEET ITEM / NAME AND DESCRIPTION OF ENTERPRISE / CONTRACTORS NET INVESTMENT / AMOUNT OF CONTRACTOR’S RATIO OF JOINT VENTURE WORKING CAPITAL /
$ / $
TOTAL / $

Part 1, Page 11

CS-4300 (11-99) Part 1

SCHEDULE F - *INVENTORIES: -MATERIALS, OPERATING-MAINTENANCE

SUPPLIES AND PARTS TO BE CONSUMED

IN COMPLETION OF CONTRACTS, OR FOR SALE

BALANCE SHEET ITEM / DESCRIPTION OF MATERIAL / QUANTITY / BOOK VALUE /
$
TOTAL / $

Part 1, Page 12

CS-4300 (11-99) Part 1

SCHEDULE G – ACCRUED INCOME

BALANCE SHEET ITEM / DESCRIPTION / DATE OF EXPECTED RECEIPT OR CREDIT / AMOUNT /
$
TOTAL / $

SCHEDULE H – PREPAID EXPENSES

BALANCE SHEET ITEM / DESCRIPTION / WHEN DUE / AMOUNT /
$
TOTAL / $

Part 1, Page 13

CS-4300 (11-99) Part 1

SCHEDULE I- PLANT PROPERTY

PART 1 – MACHINERY AND EQUIPMENT (BOOK VALUE) USED IN OPERATION OF BUSINESS

BALANCE SHEET ITEM / QUANTITY / DESCRIPTION AND CAPACITY OF ITEMS / AGE OF ITEMS / PURCHASE PRICE / DEPRECIATION CHARGED OFF / BOOK VALUE /
$ / $
TOTAL / $
Total amount of equipment pledged as security for loans / $______

Part 1, Page 14

CS-4300 (11-99) Part 1

SCHEDULE I – PLANT PROPERTY

PART 2 – LAND AND BUILDINGS (BOOK VALUE) USED IN OPERATION OF BUSINESS

BALANCE SHEET ITEM / DESCRIPTION AND LOCATION OF PROPERTY / TITLE HELD IN WHOSE NAME / TOTAL COST INCLUDING IMPROVEMENTS / ASSESSED VALUE / BOOK VALUE AFTER DEPRECIATION CHARGED OFF
$ / $ / $
TOTAL / $

SCHEDULE I – PLANT PROPERTY

PART 3 – FURNITURE AND FIXTURES (BOOK VALUE)

BALANCE SHEET ITEM / DESCRIPTION / AMOUNT (BOOK VALUE)
$
TOTAL / $

Part 1, Page 15

CS-4300 (11-99) Part 1

SCHEDULE J – OTHER ASSETS

PART 1 – LAND AND BUILDINGS OWNED BUT NOT USED IN OPERATION OF BUSINESS (BOOK VALUE)

BALANCE SHEET ITEM / DESCRIPTION AND LOCATION OF PROPERTY / TITLE HELD IN WHOSE NAME / COST / DEPRECIATION RESERVE / BOOK VALUE
$ / $ / $
TOTAL / $

SUPPLEMENTARY DATA:

For Individual or Co-Partnership Personally Owned Real Estate Not Connected with the Business

DESCRIPTION OF PROPERTY / LOCATION OF PROPERTY / TITLE HELD IN WHOSE NAME / ENCUMBRANCE AGAINST PROPERTY / ASSESSED VALUE
$ / $

SCHEDULE J – OTHER ASSETS

PART 2 – OTHER

BALANCE SHEET ITEM / DESCRIPTION: (Describe Fully) / AMOUNT
$
TOTAL / $

Part 1, Page 16

CS-4300 (11-99) Part 1

DETAILS RELATIVE TO LIABILITIES AND NET WORTH

SCHEDULE K – NOTES PAYABLE

BALANCE SHEET ITEM / PAYEE: NAME AND ADDRESS / MATURITY DATE / HOW SECURED / CURRENT PORTION (K-1) (K-2) / LONG TERM PORTION (K-3)
$ / $
TOTAL / $ / $

SCHEDULE L – ACCOUNTS PAYABLE

PART 1 – PAYABLE TO SUBCONTRACTORS

BALANCE SHEET ITEM / DESIGNATION OF CONTRACT AND NAME OF SUBCONTRACTOR / TOTAL AMOUNT OF WORK LET TO SUBCONTRACTOR / VALUE OF WORK DONE BASED ON LAST ESTIMATE APPROVED / AMOUNT PAID TO DATE / AMOUNT DUE SUBCONTRACTOR INCLUDING RETAINAGE
$ / $ / $ / $
TOTAL / $

Part 1, Page 17