Contractor's Statement of Experience, Equipment and Financial Condition

LETTER OF CREDIT

PREQUALIFICATION STATEMENTS MUST BE RECEIVED BY THE CONTRACT LETTINGS SECTION OF THE NEBRASKA DEPARTMENT OF TRANSPORTATION PRIOR TO 5:00 P.M. AT LEAST FIVE (5) DAYS BEFORE THE LETTING IN WHICH THE APPLICANT INTENDS` TO SUBMIT BIDS.

If you have any questions, please contact us at 402-479-4532. Prequalification Statements may be submitted via email or mail to the following addresses:

Email Address: ndot.contractorprequalification@nebraska.gov

Physical Address	Mailing Address

Nebraska Department of Transportation Nebraska Department of Transportation

Contract Lettings Section	Contract Lettings Section

1500 Hwy 2	PO Box 94759

Lincoln NE 68502	Lincoln NE 68509-4759

Form R-123-LC, November 2020

State of Nebraska

Department of Transportation

Contract Lettings Section

Construction Division

PO Box 94759

Lincoln NE 68509-4759

Contractor’s Statement of Experience,

Equipment and Financial Condition

Fed. I.D. No.
Unemployment Insurance Act. No.

For
Name
Business Address	Corporation
Street	P.O. Box
Partnership
City	State	Zip Code
Mailing Address	Individual
Street	P.O. Box
LLC
City	State	Zip Code
Area Code	Telephone No.	Fax No.	Email Address

Person to contact regarding this statement:

Name Area Code Telephone No.

Email address to be used for public prequalified contractor list:_______________________________________

List up to 4 email addresses you would like all addenda sent to:

Indicate the Class(es) of Work in which you desire to be Qualified

(1)	Grading

(2)	Aggregates

(3)	Concrete Pavement

(4)	Culverts

(5)	Landscaping

(6)	Bridges

(7)	Guard Rail and Fence

(8)	Miscellaneous

(8a)	Building Construction

(8b)	Electrical

(8c)	Signing

(8d)	Painting

(8e)	Demolition

(9)	Bituminous

(10)	General (All Classes)

Includes, but may not be limited to, the following items:

Armor Coat, Chip Seal, Fog Seal, Slurry Seal, Microsurfacing, Pavement Repair & Patching, Joint Repair & Patching, Joint Sealing, Crack Sealing, Dowel Bar Retrofit, Diamond Grinding, Rumble Strips, Noise Walls, Paint Striping, Bridge Painting, Mowing, Weed Spraying, Hauling & Miscellaneous

INSTRUCTIONS FOR PREQUALIFICATION USING LETTER OF CREDIT

1.	Applications for Prequalification will be accepted only on forms furnished by the Department. One copy is to be submitted to the Nebraska Department of Transportation. Reproduced copies of good quality will be accepted by the Department.

2.	The name of the person or organization being prequalified must be the proper legal name of the entity and must be shown IDENTICALLY on the Cover of this Statement, in the Letter of Credit and on the Affidavit of the Entity.

The business name used shall be such that full disclosure is assured, i.e., an individual doing business as a trade name shall include the individual's name, DBA, and the trade name.

STATE OF NEBRASKA

DEPARTMENT OF TRANSPORTATION

Letter of Credit for Pre-Qualification

(Date)
For the purpose of qualification to perform contracts on road construction with the State of Nebraska under the laws of the State of Nebraska and in order to show the financial resources for that purpose, the
hereby declares and states that
(Name of Financial Institution)
carries a line of credit with this
(Name of Contractor)
Financial Institution and/or that this Financial Institution is, at this time, willing to loan to this contractor a net
total of	$
This Letter of Credit is valid for 15 months from the date signed or until:	**.

* The name must agree with the name used on the Cover of this Statement and in the Affidavit. ** Any stipulations or restrictions to this Letter of Credit during the time period of its validity must be submitted to the Contract Lettings Section of the Nebraska Department of Transportation, PO Box 94759, Lincoln NE 68509-4759 by the Financial Institution immediately.

The general nature of the collateral which we will require to secure loans in excess of those that are outstanding at this time is as follows:

We are signing this instrument with the understanding that it is a special form of Letter of Credit that is for use only by the Department of Transportation in connection with the administration of Nebraska Revised Statutes 391351 and 39-1352 – R.R.S. 1943, in estimating the approximate amount of money which will be available for use in performing work for which the Department may award a contract or contracts to this contractor.

It is understood that an actual commitment to loan is not being made but this document expresses our carefully considered judgment of the contractor’s eligibility for a loan and our willingness at this time to loan this contractor the stipulated amount.

This information is being furnished with the further understanding that this expression of our willingness at this time to loan this contractor the stated amount of money will be given the same weight by the Department in estimating the contractor’s current assets as would cash or negotiable securities listed in a financial statement.

(Name of Financial Institution)
(Address)
By
President or Managing Officer
(Area Code) (Telephone No.)

CONTRACTOR’S QUESTIONNAIRE

(All questions must be answered and explanations furnished if required.)

1	(Corporations only) Is this corporation considered a subsidiary corporation? Yes No If yes, provide the following information:
Name and Address of Parent	Percent of Shares Owned
2	(Corporations only) Does this corporation own any subsidiaries? Yes No If yes, provide the following information.
Names and Addresses	Are Subsidiaries Consolidated in this Financial Statement	Percent of Shares Owned
Yes	No
%
%
%
%

CONTRACTOR’S QUESTIONNAIRE

All questions must be completed and a full disclosure made. The Nebraska Department of Transportation may require Form R123 statements from other entities listed herein as of the same date as of this entity.

1	How many years experience have you had:	In highway construction?	As a Prime Contractor?	As a Subcontractor?
Years	Years	Years
2	How many years has this entity operated under its present business name?
3	Has this entity operated under any other business names? Yes No If Yes, specify.
4	In what types of construction have you been mainly engaged? (specify)
5	Are you interested in more than one line of business? Yes No (If yes, choose all that apply)
☐ Heavy Highway & Bridges ☐ Mowing ☐ Weed Spraying ☐ Tree Removal ☐ Curb Ramps ☐ Building ☐ Other___________________________
6	Do you intend to sublet any portion of work awarded to you? Yes No If Yes, explain.
7	Is this entity authorized to transact business in other states? Yes No If Yes, specify.
8	Have you performed work as a prime or subcontractor for any state highway department? Yes No If Yes, which and to whom do you refer.
9	What is the largest contract you have ever completed? (Explain)
10	Are there any claims on file or suits pending against you or any of your work? Yes No If yes, state amount and character.
11	Has this entity or any of the officers, members, owners or partners, etc., in this entity ever been or are now officers, members, owners or partners, etc., in an entity that has failed in business or failed to complete work awarded? Yes No If yes, explain.
12	Does this entity or any of its officers, members, owners or partners, etc., have a financial interest and/or serve as an officer or director in any other entity filing Form R-123, “Contractor’s Statement of Experience, Equipment and Financial Condition” with the Nebraska Department of Transportation? Yes No If yes, list the organization, personnel involved and the nature of the affiliation.
13	Is this entity related through principal owners and/or stockholders, officers, directors, partners, employees or others with any other businesses or ventures in the highway construction industry which do not file for prequalification with the Nebraska Department of Transportation? Yes No If yes, describe in detail these relationships.
14	Has this entity or any of its officers, members, owners or partners, etc., ever been or are now an officer, member, owner or partner, etc., in an entity that has been denied prequalification or removed from an approved bidder’s list by this or any other state or the Federal Government? Yes No If yes, provide complete details including when, where and why.
15	Has anyone been obliged to pay a loss on account of having become surety for you? Yes No If yes, explain.
16	Provide a list of all principals, officers, partners, companies or organizations owning any part of this entity.
17	Property List all temporary and permanent plants, borrow sites, waste sites, plant sites owned by the contractor.
Description	Location (address, city, state, lat./long.)

Bid Submittal Using Bid Express

For Contractors who elect to submit bids via Bid Express/BidX: The Nebraska Department of Transportation (NDOT) has developed procedures for contractors who choose to submit bids over the internet for work being let through NDOT. By signing this prequalification statement, the bidder agrees: A bid received from a bidder who was not issued an “Authorization to Bid” will be considered invalid and will not be read. Bids will be electronically submitted to Info Tech., Inc. of Gainesville, Florida, as an independent depository for the electronic bid submission, and that NDOT will not have access to these bids until after the deadline for bid submittal. The bidder will obtain, at their sole expense, a Bid Express account from Info Tech, Inc., including a unique Digital ID for each individual signing the bids. The bidder will ensure the confidentiality of the Digital IDs. The bid must be signed by an officer authorized to sign bids as stated on the “Corporation Information Sheet” or the “Appointee and Signature Authorization” sheet of the Contractor’s Statement of Experience and Financial Condition. The submission of a digitally signed electronic bid constitutes the signature on the electronic bid. The submission of a digitally signed electronic bid also certifies acceptance of the bidder’s acknowledgements and certifications that are covered by the signing of the bid signature page. The end of the transmission of the electronic bid from the contractor to Info Tech, Inc. will be considered as the time the electronic bid was submitted. A paper bid submitted shall be considered the Contractor’s bid in the case where the Contractor submits both a paper bid and an electronic bid.

On-The-Job Training Program

By signing this prequalification statement, your company agrees to the terms and conditions set forth in the “NDOT Contractor Specific On-the-Job Training Program”. A copy of the “NDOT Contractor Specific On-the-Job Training Program – Training Special Provisions” can be found on the NDOT website.

Corporation Information Sheet

This form is to be completed if the entity is a corporation.

Print or Type

Name as Incorporated:	Date Incorporated:
In What State Incorporated:	Directors:
President:
Vice-President:
Secretary:
Treasurer:
The officers and employees listed below are appointed and authorized by the Board of Directors to approve and execute the following documents on the Corporation’s behalf:
Contractor’s Statement of Experience, Equipment and Financial Condition (Prequalification) Paper/Electronic Bids/Contracts/Bonds If any changes are made in the appointee list by the action of the Board of Directors during the term of this Financial Prequalification, the corporation shall submit a document advising of such action to the Contract Lettings Section, Nebraska Department of Transportation.
Name	Title	Email	Prequal	Paper\ Electronic Bids/ Contracts/ Bonds

Use copies of this sheet for additional entries.

Appointee and Signature Authorization

This form is to be completed if the entity is an Individual, Partnership or Limited Liability Company or any combination of these entities
THE PERSON(S) LISTED BELOW ARE AUTHORIZED TO APPROVE AND EXECUTE ON BEHALF OF THE LIMITED LIABILITY COMPANY, PARTNERSHIP(S), AND/OR INDIVIDUAL(S) NAMED HEREIN, THE FOLLOWING DOCUMENTS: Contractor’s Statement of Experience, Equipment and Financial Condition (Prequalification) Paper/Electronic Bids/Contracts/Bonds
Name of Company or Companies:
State Formed:
Name	Title	Email	Prequal	Paper\ Electronic Bids/ Contracts/ Bonds
If any changes are made in the authorization list during the term of this Financial Prequalification, the entity shall submit a document advising of such action to the Contract Lettings Section, Nebraska Department of Transportation.

Affidavit

(Notarized)

STATE OF
COUNTY OF
The undersigned, being duly sworn, hereby declares that the statements herein contained are true and correct.
It is understood that this statement is for the express purpose of obtaining prequalification to bid on work let to contract by the Nebraska Department of Transportation; and that any entity, vendor or agency herein named is hereby authorized to supply the Department with any information necessary to verify this statement.
Subscribed and sworn to before me this
day of	Name of Firm
(month)	(year)	By * Title
Notary Public
My commission expires

* For an individual business, the affidavit is to be signed by the owner and notarized. For a partnership or LLC, the affidavit is to be signed by all partners or members and notarized.

* For a corporation, the affidavit is to be signed by an authorized official and notarized. Corporations must affix their corporate seal or indicate “No Seal.”

* Any false, deceptive or fraudulent statements made herein by the applicant may be cause for disqualification as a future bidder on projects let by the Nebraska Department of Transportation.