Contractor's Statement of Experience, Equipment and Financial Condition
Certificate of Surety
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 Nebraska Department of Transportation Contract Lettings Section 1500 Nebraska Pkwy Lincoln NE 68502	Physical Address Nebraska Department of Transportation Contract Lettings Section PO Box 94759 Lincoln NE 68509-4759

Form R-123-CS, July 2025

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 Certificate of Surety

Applications for Prequalification will be accepted only on forms furnished by the Department.

The name of the person or organization being prequalified must be the proper legal name of the entity as registered with the Nebraska Secretary of State, and must be shown IDENTICALLY on the Cover of this Statement, in the Certificate of Surety, and in the Affidavit of the Entity.

The applicant shall furnish a certified statement from a bonding agency licensed to do business in the state of Nebraska.

The certification shall be on bonding agency letterhead and indicate the total maximum bonding coverage the surety will issue on the applicant’s behalf (without consideration given to uncompleted contracts). A sample Certification of Surety is included in this form. The actual certification shall be identical to the sample as to form and content (red lettering on the sample must be removed on the actual certification).

The “maximum qualification” rating will not exceed the bonding limitation established by the surety on the contractor’s behalf, and under certain circumstances, may be lower.

The Certification of Surety Form will stand independently from any other documents submitted to the state, and any limitations or exclusions set forth on the Certification of Surety will not be considered as a limitation or exclusion on any bonds that have been (or will be) issued by the surety company to the contractor. Rescission of the Certification of Surety does not serve as revocation, cancellation or repeal of any bonds issued to the contractor.

Prequalification will expire 15 months from the date of the Certification of Surety, or according to the expiration date as shown on the Certification of Surety, not to exceed 15 months.

The “maximum qualification” rating will conform to the bonding limitations established by the surety on the contractor’s behalf. The Department may reduce or revoke the contractor’s prequalification rating, based on the contractor’s performance record with regard to quality of work, timely completion, or other pertinent factors. Unsatisfactory ratings in NDOT’s Contractor Evaluation Program will result in a reduced maximum prequalification amount.

Sample Certificate of Surety

To be printed on agency letterhead

Date: _______________________________

To:	Contracts Section

Nebraska Department of Transportation

1500 Highway 2

Lincoln NE 68502

ndot.contractorprequalification@nebraska.gov

___________________________________________________________________________________

Contractor’s Name (as registered with Secretary of State)

_____________________________________________________________________________________

City, State, Zip

I am hereby authorized on behalf of ________________________________________________, a surety licensed in
(Surety Company Name)
Nebraska, to execute bid, performance, and payment bonds for the above contractor subject to the following conditions:

1.	Maximum bonding capacity (without consideration given to uncompleted contracts) $__________________________________.

2.	This Certificate of Surety expires on ___________________________(not to exceed 15 months from the date the Certificate of Surety is signed. If no date is specified, 15 months from date signed will be used), unless previously rescinded in writing. Written notice of rescission will be provided to the Nebraska Department of Transportation, at the above address, within five (5) days of such rescission.

I am signing this instrument with the understanding that it is a special surety form that is for use only by the Department of Transportation in connection with the administration of Nebraska Revised Statutes 39-1351 and 39-1352, in estimating the appropriate amount of bond credit which will be available for use for which the Department may award a contract or contracts to this contractor.

It is understood that an actual commitment to execute bonds on behalf of aforementioned surety is not being made but this document expresses our carefully considered judgement of the contractor’s bonding capacity and our willingness at this time to extend this contractor the stipulated bond amount. No commitment is made to utilize the surety for bonding purposes.

Agency Name: _____________________________________________

Agency Nebraska License Number: ______________________________________

By: _______________________________________________________

(Agent Printed Name and Nebraska License Number)

___________________________________________________________

(Signature of Agent)	(Date)

A copy of the Nebraska licenses for both the agency and agent must be attached to this statement.

Contractor’s Organization 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
%
%
%
%

3. Please list all affiliated companies (excluding joint ventures) and their relationship:

Contractor’s Questionnaire

All questions must be completed and a full disclosure made.

1	How many years experience:	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 Construction ☐ 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 this entity? Yes No If yes, state amount and character.
11	Has this entity or any of the officers, members, owners or partners, or any other entity management position, in this entity ever been or are now officers, members, owners or partners, or other entity management position, 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, or other entity management position, 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 or 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, or other management position, ever been or are now an officer, member, owner or partner, or other management position, 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 the reason for denial.
15	Has a surety company been obliged to pay a loss on account of having become surety for this entity or any related entity referenced above? Yes No If yes, explain.
16	Provide a list of all principals, officers, partners, companies or organizations owning or having a financial interest in 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.