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prevented from bidding on, or completing, any government agency project for any reason?
<br />❑ Yes ❑ No
<br />If "yes," explain on a separate page. State the name of the organization debarred, the year of
<br />the event, the owner of the project, and the basis for the action.
<br />In the past five years, has any claim against your firm concerning your firm's work on a project,
<br />been filed in court or arbitration?
<br />❑ Yes ❑ No
<br />If "yes," on a separate page identify the claim(s) by providing the project name, date of the
<br />claim, name of the claimant, the name of the entity the claim was filed against, a brief
<br />description of the nature of the claim, the court and case number, and a brief description of the
<br />status of the claim (pending or, if resolved, a brief description of the resolution.)
<br />10. In the past five years, has your firm made any claim against a project owner concerning work
<br />on a project or payment for a contract, and filed that claim in court or arbitration?
<br />❑ Yes ❑ No
<br />If "yes," on a separate page identify the claim(s) by providing the project name, date of the
<br />claim, name of the claimant, the name of the entity the claim was filed against, a brief
<br />description of the nature of the claim, the court and case number, and a brief description of the
<br />status of the claim (pending or, if resolved, a brief description of the resolution.)
<br />11. At any time during the past five years, has any surety company made any payments on your
<br />firm's behalf as a result of a default, to satisfy any claims made against a performance or
<br />payment bond issued on your firm's behalf in connection with a project, either public or
<br />private?
<br />❑ Yes ❑ No
<br />12. In the last five years, has any insurance carrier, for any form of insurance, refused to renew
<br />the insurance policy for your firm?
<br />❑ Yes ❑ No
<br />13. Has your firm or any of its owners, officers, or partners ever been liable in a civil suit, or found
<br />guilty in a criminal action, for making any false claim or material misrepresentation to any
<br />public agency or entity?
<br />❑ Yes ❑ No
<br />14. Has your firm or any of its owners, officers or partners ever been convicted of a federal or
<br />state crime of fraud, theft, or any other act of dishonesty?
<br />❑ Yes ❑ No
<br />If "yes," identify on a separate page, the person or persons convicted, the court case and
<br />number, the crimes and the year convicted.
<br />15. If your firm was required to pay a premium of more than one percent for a performance and
<br />payment bond on any project(s) on which your firm worked at any time during the last three
<br />years, state the percentage that your firm was required to pay. You may provide an
<br />explanation for a percentage rate higher than one percent, if you wish to do so.
<br />Park Janitorial Maintenance Services RFP 14 -002
<br />Page 37
<br />19C -39
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