This form is available on the Village of Bellevue website
www.villageofbellevue.org
VILLAGE OF BELLEVUE BIDDERS
PROOF OF RESPONSIBILITY
ALL BIDDERS ON PUBLIC WORKS CONTRACTS
SHALL PROVIDE PROOF OF RESPONSIBILITY IN ACCORDANCE
WITH SECTION 66.0901 (2), WISCONSIN STATUTES
THIS PROOF OF RESPONSIBILITY
SHALL EXPIRE ON DECEMBER 31 OF THE ODD YEAR
AFTER THE DATE OF FILING
WITH THE PUBLIC WORKS DIRECTOR
NOTE
THE CONTENTS OF THIS QUESTIONAIRE SHALL BE CONFIDENTIAL
FOR THE EXCLUSIVE USE OF THE CONTRACTING AGENCY
AND SHALL NOT BE MADE PUBLIC EXCEPT
BY WRITTEN PERMISSION OF THE PROSPECTIVE BIDDER.
(DO NOT REMOVE THIS COVER SHEET FROM DOCUMENT)
IDENTIFICATION
A.
Official Firm Name
B.
Telephone
C.
Address
Fax
E-mail
(Street)
(City)
(PO Box)
(State)
(Zip Code)
D.
Number of years in business under present firm name
E.
Please check (1), (2), or (3):
(1) A Corporation
(2) A Co-Partnership
(3) An Individual
Federal Tax Identification No.
F.
G.
Principal Individuals:
(If a Corporation, answer below)
(If a Co-Partnership, answer below)
President
Name of Partner
Vice Pres.
Name of Partner
Secretary
(If a Sole Trader, answer below)
Treasurer
Name of Sole Trader
If a Corporation, answer below:
(1)
When incorporated
Village of Bellevue Proof of Responsibility
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, (2) In what State
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H.
Class of work in which firm is seeking qualifications (check below):
STREET, UTILITY AND SITE CONSTRUCTION
BUILDING CONSTRUCTION

Bituminous street construction
(Prime contractor)


Bituminous paving
General Building Construction
(New construction, renovations, or
remodeling)

Bridge construction and repairs

$0 - $100,000

$0 - $250,000

$100,000 - $250,000

$250,000 - $500,000

Over $250,000

Over $500,000

Bridge painting

Concrete street construction
(Prime contractor)
Specific Categories Of Building Construction

Asbestos abatement

Building demolition

Concrete paving

Electrical

Concrete pavement repairs

Elevator

Joint sealing

Fire protection

Landscaping

Heating, ventilating, and air conditioning

Mudjacking

Painting

Pile driving

Plumbing

Pump houses & lift stations

Roofing

Reinforced concrete construction
(such as foundations, storm drainage
structures, retaining walls)
OTHER MISCELLANEOUS CATEGORIES

Roadway grading & graveling


Sanitary and storm sewer construction

Lateral construction only


Sidewalk construction


Site excavation and grading and graveling


Street lighting

Water main construction

Lateral construction only
Village of Bellevue Proof of Responsibility
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

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EXPERIENCE
A. What is the construction experience of the principal individuals, including superintendents and/or foremen,
of your present organization?
Individual's Name
Present Position of
Officer in your
Organization
Magnitude and
Type of Work
Years of
Construction
Experience
In What
Capacity
Average number of employees during the last 12 months:
Office
Skilled
Unskilled
B. CONSTRUCTION EXPERIENCE
List below construction work performed by you of any projects pertinent to the type of work for which prequalification is desired.
Under "Capacity", state whether as Contractor, Engineer, Superintendent,
Foreman, etc.
YEAR
TYPE OF WORK
CAPACITY
COST OF WORK
C. WORK ON HAND
List below the present contracts held by you.
DATE AWARDED
TYPE OF
WORK
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PERCENT
COMPLETED
ANTICIPATED
COMPLETION DATE
COST OF WORK
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EQUIPMENT
A. List below major pieces of equipment owned and available when needed for proposed work. ALL
COLUMNS MUST BE COMPLETED.
ATTACH ADDITIONAL SHEETS IF NECESSARY.
MUST
CONTAIN SAME INFORMATION LISTED ON THIS PAGE.
NUMBERS
OF ITEM
DESCRIPTION
SIZE, CAPACITY,
ETC.
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ORIGINAL
COST
ACCUMULATED
DEPRECIATION
PRESENT
BOOK
VALUE
YEARS OF
SERVICE
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CONTRACTUAL RESPONSIBILITY
A. Has firm ever failed in the past ten years to complete on time work awarded to it?
If so, state:
Date
Owner
Owner's Mailing Address
(At that time, or now--preferably now, if there is a difference.)
Full particulars in each instance:
B. Has any officer or partner or firm ever failed in the past ten years to complete on time a construction
contract handled in his own name?
If so, state:
Date
Name of Officer
or Partner
Owner
Owner's Mailing Address
(At that time, or now--preferably now, if there is a difference)
Full particulars in each instance:
C. Has any officer or partner of firm ever been an officer or partner of some other organization during the past
ten years that failed to complete on time a construction contract?
If so, state:
Date
Name of Officer
or Partner
Name of Mailing Address of Organization
Name and Mailing Address of Owner
(Above addresses at that time, or now--preferably now, if there is a difference.)
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Full particulars in each instance:
D. Has firm asked to be relieved from a bid submitted by it to a public awarding authority during the past 10
years?
If so, state:
Date
Claimant
Owner's Mailing Address
(At that time, or now--preferably now if there is a difference.)
Full particulars in each instance:
E. Has firm ever been charged with or convicted of a violation of any wage schedule?
If so, state:
Date
Claimant
Claimant's Mailing Address
(At that time, or now--preferably now, if there is a difference.)
Full particulars in each instance:
F.
Has the applicant, any of its owners, a subsidiary or corporate parent, or any officer or director thereof,
been convicted in the last three years of violating Section 133.01, Wisconsin Statutes (Unlawful Contracts:
Conspiracies)?
If so, state:
Date
Claimant
Claimant's Mailing Address
(At that time, or now--preferably now, if there is a difference.)
Full particulars in each instance:
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A. Names, addresses, and telephone numbers of bonding companies which generally execute bid and surety
bonds:
Names, addresses, and telephone numbers of all bonding companies other than those listed in A above
which have written bid and surety bonds during the last five years:
B. Has any bonding company ever taken over a contract, or made any payments because of firm's failure to
carry out a contract?
If so, state:
Date
Name of Bonding Co.
Bonding Company's Mailing Address
Full particulars in each instance:
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CONTRACTOR'S FINANCIAL STATEMENT
Condition at close of business of
, 20
A. ASSETS
Cash
.......................................................................... $
Accounts Receivable.......................................................... $
Real Estate Equity.............................................................. $
Materials in Stock ............................................................... $
Equipment - Book Value .................................................... $
Less Depreciation
Furniture and Fixtures - Book Value................................... $
Less Depreciation
Other Assets ...................................................................... $
TOTAL ASSETS .......................................................... $
B. LIABILITIES
Accounts, Notes, and Interest Payable .............................. $
Other Liabilities .................................................................. $
TOTAL LIABILITIES .................................................... $
NET WORTH (TOTAL ASSETS - TOTAL LIABILITIES) ............ $
C. Who prepared such balance sheet?
D. Are any of your assets assigned; if so, which are assigned?
For what purpose are they assigned?
E.
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DATA
A. Are you familiar with the provisions of the form of contract used by the Village of Bellevue?
B. With its terms and conditions?
C. With its specifications?
D. With the regulations of the Village of Bellevue relating to bidding and awarding of contracts?
E. List at least three references for whom you have performed work and GIVE COMPLETE
NAMES, TITLES, ADDRESSES, PHONE NUMBERS, AND DOLLAR VOLUME OF WORK
INVOLVED in all references.
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AFFIDAVIT
STATE OF
)
COUNTY OF
)
being duly sworn, deposes and says that
he/she (Name of Officer/Owner)
is the
of
(Title)
(Name of Firm)
and that the answers to the foregoing questions and all statements therein contained are true and
correct, and that any owner, bonding company, or other agency, herein named is hereby authorized
to supply the municipality, Village of Bellevue, with any information deemed necessary to verify this
statement.
(Signature of Officer/Owner)
Subscribed and sworn before me this
day of
. 20
.
Notary Public
,
County
State
My Commission Expires
APPROVED BY:
Date
Director of Public Works
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