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Statement of Experience & Financial Condition

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Statement of Experience & Financial Condition

    Statement of Experience and

    Financial Condition (SEFC)

FIRM NAME:

    THE FIRM’S FISCAL YEAR ENDING DATE ,

    Month - day Year (firm’s last complete fiscal year)

    CURRENT DATE (The Submittal Date) ,

SUBMIT COMPLETED SEFC IN DUPLICATE TO:

Illinois Department of Transportation

    Bureau of Design & Environment

    Attn: Chief of Preliminary Engineering

    Consultant Services Unit

    2300 South Dirksen Parkway, Room 330

    Springfield, Illinois 62764

    SEFC and Description & Minimum Requirements: http://www.dot.il.gov/desenv/preqcons.html

Printed 4/5/2012 Page 1 BDE SEFC TEMPLATE (Rev. 10/01/11)

    General Information for Engineering Consultants

    The Illinois Department of Transportation utilizes Engineering Consultants per the required laws & codes.

    ; The Law: (30 ILCS 535) Architectural, Engineering, and Land Surveying Qualifications Based Selection (QBS) Act

    ; Administrative Code: Title 44, Subtitle B Chapter IX Part 625 Selection of Architect-Engineer Consultant Firms

    http://www.dot.il.gov contains extensive information. Most information needed will be under Doing Business: The IDOT Web-Site:

    http://www.dot.il.gov/dobuisns.html/dobuisns.html

The Bureau of Design and Environment Manual is available on the IDOT web-site under Doing Business, Manuals Memorandums

    Rules http://www.dot.il.gov/desenv/demanuals.html. The Bureau of Design and Environment Manuals & Memorandums BDE Manual -- Chapter 8 (CONSULTANT DEVELOPED and/or DESIGNED PROJECT) contains:

    ; Definition of terms

    ; Prequalification of Engineering Firms

    ; Submittal and selection process for the Professional Transportation Bulletin

    ; Negotiation and contract information

    There are also memorandums, which are updates to the BDE Manual and should be reviewed at this location.

Prequalification information is also under Doing Business Consultant Services - Consultant Prequalification Questions regarding

    Engineering Consultant Prequalification may be directed to the Bureau of Design and Environment, Consultant Unit, Carrie Kowalski,

    Carrie.Kowalski@illinois.gov or phone 217-782-6916.

All firms doing engineering for IDOT must be prequalified in the category of work they are providing. Firms doing work as a prime or a

    sub must be prequalified and must go through the same prequalification process. Once prequalified, firms can submit Statements of

    Interest for Professional Transportation Bulletin.

    Professional Transportation Bulletins are located at: http://www.dot.il.gov/desenv/ptb.html

    Firm’s that also wish to be a DBE must be certified through the Illinois Unified Certification Program. IDOT DBE Certification is done through Small Business Enterprises. Their information is also located Under Doing Business. Note that Prequalification and Certification are two separate processes and can be done simultaneously. To become a certified DBE:

    ; The firm must complete and submit an Illinois Certification Program “Uniform Certification Application,” plus all

    required/requested information. The application is available on IDOT’s web site (www.dot.il.gov/ucp/ucp.html) or by contacting

    IDOT’s Bureau of Small Business Enterprises at 217/782-5490.

Printed 4/5/2012 Page 2 BDE SEFC TEMPLATE (Rev. 10/01/11)

    SEFC INSTRUCTIONS

    Firms seeking prequalification for the first time, or firm’s that have lost their prequalification status, must submit the Entire SEFC. All prequalified firms are required to submit their entire SEFC every 3 years, which is based on the chart below. The corporate and

    financial portions of the Statement of Experience and Financial Condition are required every year. The fiscal year is the firm’s fiscal year. A firm has 6 months from their end FY date to resubmit the applicable portion of the SEFC. If the firm fails to submit by the due

    date, prequalification is lost until the entire SEFC has been resubmitted by the firm, then reviewed, and approved by IDOT.

    The date below is when the firm is actually submitting, i.e. if your firm’s fiscal year ends 12-31-2011, you will be submitting your data in 2012. If your firm is Engineering ABC & your fiscal year, ending date is 12-31-2011 then the corporate and financial portion will be

    due by June 30, 2012. If your firm is Smith Engineers with a FY 12-31-11 end date then the entire SEFC is due by June 30, 2012.

    The year date shown is when the SEFC is submitted

    Firm Name 2012 2013 2014 2015 2016 2017 2018 2019 Beginning with:

    A through E Corp. & Entire Corp. & Corp. & Entire Corp. & Corp. & Entire

    Financial SEFC Financial Financial SEFC Financial Financial SEFC

    F through N Corp. & Corp. & Entire Corp. & Corp. & Entire Corp. & Corp. &

    Financial Financial SEFC Financial Financial SEFC Financial Financial

    O through Z Entire Corp. & Corp. & Entire Corp. & Corp. & Entire Corp. &

    SEFC Financial Financial SEFC Financial Financial SEFC Financial

    CORPORATE AND FINANCIAL (DUE ANNUALLY)

; Corporate and Financial Portion is required annually and consists of Page 1 - 5 and applicable to page16. (submittal must be

    complete, do not submit partially done SEFC)

; Before submitting review your submittal for completeness

     Downloaded and are using most current SEFC (note the footer reflects the correct revision date).

    http://www.dot.il.gov/desenv/preqcons.html

     (Firms are required to use the latest version. Submittals not using the latest version will not be reviewed and your firm will be

    denied prequalification.)

     All yes/no, boxes are completed

     Address/contact information is accurate Page 5

Printed 4/5/2012 Page 3 BDE SEFC TEMPLATE (Rev. 10/01/11)

    SEFC INSTRUCTIONS

    The Attachments are included:

     The EEO Policy/Program (page 7 or 8)

     If incorporated the Certificate of Good Standing from the Illinois Secretary of State (page 7)

     IL Department of Financial and Professional Regulation License (page 7 or 10) (Your firm must be registered for most

    categoires)

     Time-stamped certificate of registration or a copy of the certificate of registration with State Board of Elections (page 7 or 10)

     If your firm is a DBE, a copy of the certification document is required (page 8 & 11)

The applicable financial information required is included (page 12) (check one)

     We provided an approved audit from another STATE or FEDERAL AGENCY for our last fiscal year.

     We provided a chart of accounts, overhead rate calculation, and our tax return (a tax extension is acceptable, to remain

    prequalified the completed return must be submitted by extension deadline) for our last fiscal year

     We are a new firm and have at least six months fiscal data, and have submitted written justification accompanying the

    data explaining why the Firm should be exempted.

     We are supplying our prevailing rate schedule

     The overhead rate is included in the space provided on page 14

     Cost accounting standards information page 15 has been completed

     Taxpayer Identification number and Notary page 16 has been completed

SEFC Staffing and Experience Section (every third year, if currently prequalified)

     Totals are correct on pages 18, 19, and 20 (the rows and/or columns have been reviewed and are added correctly)

     The registered professional are listed on page 18

     Prequalification categories have been marked on page 22

     When listing projects, the projects are within the time frame required in the Description and Minimum Requirements, no more than 10 projects per category, and at least on principal supervisory person in charge of project

     The project descriptions meet the criteria of the description and minimum requirements for the category

    Printed 4/5/2012 Page 4 BDE SEFC TEMPLATE (Rev. 10/01/11)

The questionnaires are completed for the specific category(s) requested and in the questionnaire format.

Printed 4/5/2012 Page 5 BDE SEFC TEMPLATE (Rev. 10/01/11)

    STATE OF ILLINOIS DEPARTMENT OF TRANSPORTATION

    The information requested in this booklet must be furnished to the Department of Transportation in order to become prequalified for professional work for the Department. Information furnished will be held in the strictest confidence and used only on a “need to know” basis by the Department and the Federal Highway Administration for fiscal and technical evaluation. This information may be audited or verified as deemed necessary by the Department.

    (Name of Firm)

     (Address) (Telephone) (Fax Number) (Contact Person) Main Office*

*If prequalification correspondence should be addressed elsewhere, give name and address here:

    (this is the person that will be contacted regarding the SEFC application)

For Statement of Experience and Financial Condition Name:

    (SEFC) correspondence give name & e-mail address

    here: E-Mail:

    To receive updates related to the Prequalification of Consultant Engineering Firms, the Publishing of the Professional Transportation Bulletin, or other information related to Consultant Engineering through the free subscription service; please follow the instructions for subscribing at http://www.dot.il.gov/desenv/ptbsubsc.html

     List branch offices on a supplemental attachment and include after this page.

How many years of experience does this Firm have in transportation work?

Printed 4/5/2012 Page 6 BDE SEFC TEMPLATE (Rev. 10/01/11)

    CORPORATE AND

    FINANCIAL

    INFORMATION

Printed 4/5/2012 Page 7 BDE SEFC TEMPLATE (Rev. 10/01/11)

    CORPORATE INFORMATION

    (If a Corporation, Answer these Questions)

1. When incorporated? Which State?

     Month/Year

    Your firm must be certified by the Secretary of State to do business in Illinois. Attach a copy of the Current Certificate for initial 2.

    applicants or a current Certificate of Good Standing for others. Document may be obtained from the Illinois Secretary of State, web

    site: http://www.cyberdriveillinois.com/home.html

    Your firm must be licensed by the Illinois Department of Financial and Professional Regulation for the type of work your firm will be 3.

    completing. Check ( ) the appropriate box (es), complete the license number and attach a copy of the license.

    http://www.idfpr.com/

     Corporation Partnership Limited Liability Corporation Limited Liability Partnership

     Professional/Design Firm Sole Proprietorship

     ARCH PE SE LS ARCH PE SE LS

     #184- Individual Registration #

     Professional Service Corp. With Assumed Name

     ARCH PE SE LS #184-

     #060-

4. Give name and address of Illinois registered managing agent(s) for each that apply to the firm:

    Activities Name and address

     Architectural

     Professional Engineering

     Structural Engineering

     Land Surveying

    Attach a copy of the current affirmative action program the Firm follows to insure that all prequalified applicants for employment 5

    and all employees are considered without regard to race, color, sex or national origin. All firms, regardless of size, must submit a

    statement of policy every year.

    6. Your firm must register as a business entity with the State Board of Elections, and acknowledges a continuing duty to update the

    registration pursuant to the Procurement Code (30 ILS 500/20-160). Attach a copy of the time-stamped certificate of registration or

    a copy of the certificate of registration. The Department will not execute a contract without the certificate of registration.

    http://www.elections.state.il.us/Default.aspx

    Printed 4/5/2012 Page 8 BDE SEFC TEMPLATE (Rev. 10/01/11)

    CORPORATE INFORMATION

    (Continued)

    7. List all officers and directors and all entities or individuals owning beneficial interest of 5% or more in the enterprise:

    Check if Prof. Eng. Name Title Minority % Owned Director Registration #

    Answer all questions. Yes or No must be checked 8. Is the corporation a Certified DBE Illinois Unified Certification Program? yes or no

    If yes, attach a copy of the certificate and/or letter stating the firm’s status after this page.

    9. Is the corporation, or any officer or director engaged in any other line of business? yes or no If yes, list

     such person(s), the Firm and nature of business and the extent of such person’s interest therein.

    10. Has the corporation ever been in bankruptcy or receivership? yes or no If yes, state when and explain fully.

    11. Is the corporation in any way an outgrowth, result, continuation, or reorganization of a former business? yes or no

     If yes, give name and address of each predecessor business and the date of the change in entity.

Printed 4/5/2012 Page 9 BDE SEFC TEMPLATE (Rev. 10/01/11)

    CORPORATE INFORMATION

    (Continued)

12. Name, address and percent of ownership held by parent company, if any.

     Does parent company own or control other professional firm(s)? yes or no If yes, attach details.

     Name and address of subsidiaries, if any.

13. Attach the same information for parent company and your subsidiaries as requested in the previous Item 7. Significant

    changes in ownership of the Firm, parent company or your subsidiaries must be reported in writing to the Department

    within fifteen days of when they occur.

14. Does the corporation carry any of the insurances listed below? yes or no If yes, list below.

     Insurance Amount Per Expiration Date Aggregate Amount Company Name Occurrence

    General Liability

    Automobile Liability

    Excess/Umbrella

    Workers Comp & Employer’s Liability

15. List States in which the corporation is authorized to work.

16. Is an individual, a member of a partnership, or an officer or director of a corporation interested financially in more than

    one company, yes or no If yes, then the accountant shall submit a letter explaining such interest, the extent of the

    investment, and the individual’s relationship with such companies. The Department may require these individuals to

    furnish statements from these companies as of the same date as the financial statement submitted by the applicant

    requesting prequalification.

     List individuals:

Printed 4/5/2012 Page 10 BDE SEFC TEMPLATE (Rev. 10/01/11)

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