Ps Form 5472 - Pre-Award Questionnaire And Assets And Liabilities Statement

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Pre-Award Questionnaire
and Assets and Liabilities Statement
Solicitation No.
Name (as shown on bid)
Telephone No. (include area code)
6. City
®
Address (number, street, suite, apt., P.O. Box, etc.)
7. State
8. ZIP+4
1. Nature of Bidder (sole proprietorship, partnership, corporation, etc.)
a. If Sole Proprietorship
Name of Owner
Date
b. If operating as a Partnership, Attach List of Names, Ages, and Percentage of Ownership of All Partners
c. If operating as a Corporation, Date and State of Incorporation (Attach list of names of corporate officers and majority stockholders, if any, other than officers.)
2. Describe other business ventures in which the company is, or has been engaged within the past three years. If company has not been engaged full time in
business for at least three years, identify the employment and business ventures of the owner, partners, or corporate officers during the period. (Attach
additional sheets as necessary to fully explain previous business ventures.)
3. Identify any capacity (e.g., contractor, subcontractor, carrier, driver, etc.) in which the company, its owner, partners, or officers have been engaged in the
carrying of the mails within the past five years. If possible, identify routes by number and provide name of contractor and Contracting Officer. If service on
any route was terminated by the Postal Service™ for cause, attach explanation.
4. Describe by model, size, and year, the equipment you propose to use on this route. Is the equipment owned or leased? If equipment is not yet acquired,
describe the manner proposed for its acquisition.
5. Identify any individual owner, partner, corporate officer, or majority stockholder who is an employee of the U.S. Postal Service ® , or who is either the spouse or
minor child of an employee of the U.S. Postal Service, or a blood relative of an employee of the U.S. Postal Service residing in the same household with that
postal employee. With respect to any affirmative response, identify the postal employee by name and place of work. Postal employees for the purpose of this
response include those in full-time, part-time, career and noncareer positions, including specifically persons in positions such as postmaster replacements and
rural carrier reliefs.
6. Identify the individuals (owner, partners, officers, employees, etc.) intended to have access to the mails or to postal operations areas during performance of the
contract. Indicate which individuals, if any, have previously been screened by the Postal Service for such access.
5472,
PS Form
April 2006 (Page 1 of 2) PSN 7530-02-000-9254

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