Contractor's Statement of Experience, Equipment and Financial Condition
AUDITED FINANCIAL STATEMENT
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-FS, 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:

CONTRACTOR’S

STATEMENT OF EXPERIENCE, EQUIPMENT

AND FINANCIAL CONDITION

TABLE OF CONTENTS

PAGE NO.

TABLE OF CONTENTS	2

CLASS OF WORK DESIRED FOR QUALIFICATION	3

INSTRUCTIONS TO ACCOUNTANTS FOR PREPARING FINANCIAL STATEMENTS	4

CONTRACTOR’S BALANCE SHEET (Pages 5-6)

Assets	5

Liabilities and Capital	6

Accountant’s Questionnaire	7, 8

Independent Auditor’s Report (Financial Statement)	9

Contractor’s Questionnaire	10, 11, 12

Bid Express Authorization	13

Corporation Information Sheet	14

Appointee and Signature Authorization	15

Affidavit	16

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 TO ACCOUNTANTS FOR PREPARING FINANCIAL STATEMENTS

The accountant preparing contractor's financial statements will adhere to the generally accepted auditing standards as adopted by the American Institute of Certified Public Accountants. Reviews or compilations are not acceptable.

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 of the Form R123FS, “Contractor's Statement of Experience, Equipment and Financial Condition” will be accepted by the Department.

2.	The statement shall show the condition of business as determined under generally accepted accounting principles.

3.	The date of the report need not necessarily be the contractor's fiscal year; however, the reporting period should be consistent from year to year.

4.	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 Independent Auditor's Report, and in 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. A CORPORATION FILING A CONSOLIDATED STATEMENT SHALL FULLY DISCLOSE THE IDENTITIES OF SUCH ENTITIES CONSOLIDATED.

5.	The Financial Statement Data shall be certified by a Public Accountant holding a currently valid permit from the Nebraska State Board of Public Accountancy, or by any Certified Public Accountant holding a currently valid permit. Whenever the term Certified Public Accountant appears on said form, it shall be construed to include a Public Accountant holding a valid permit from the Nebraska State Board of Public Accountancy. If additional schedules, notes and addenda are attached to Form R-123FS by the CPA, their opinion will then necessarily extend to these documents.

6.	The Financial Statements SHALL NOT be prepared and certified by an accountant who has directly or indirectly a financial interest in, or is connected with the business of the contractor submitting the statement.

CONTRACTOR'S BALANCE SHEET
(Pages 5 and 6)

This statement shall be completed in all aspects. The use of cents is not necessary. Any further rounding of figures must be explained. The classification of Assets and Liabilities between current and non-current should be based on accounting principles generally recognized as criteria for classifications.

ACCOUNTANT'S QUESTIONNAIRE

(Pages 7 and 8)

All questions must be answered and explanations furnished if required.

NAME
AS OF	, 20

- ASSETS -

SCHEDULE NUMBER	CURRENT	NONCURRENT	TOTAL
CASH	$	$

1	INVESTMENTS
MARKET VALUE
U.S. Government Obligations	$	$
Listed Securities
Securities of Affiliated Organizations
Partnerships or Joint Ventures
Others
TOTAL INVESTMENTS	$	$	$

2	NOTES RECEIVABLE
a	From Officers, Directors, Stockholders, or Partners	$	$
b	From Affiliated Companies, Partnerships, Organizations, Joint Ventures, Etc.
From Other Contractors
From Others
Less Allowances for Estimated Losses	< >	< >
TOTAL NOTES RECEIVABLE	$	$	$

3	ACCOUNTS RECEIVABLE
From Completed Contracts	$	$
From Uncompleted Contracts
a	From Officers, Directors, Stockholders, or Partners
b	From Affiliated Companies, Partnerships, Organizations, Joint Ventures, Etc.
From Others
Less Allowances for Estimated Losses	< >	< >
TOTAL ACCOUNTS RECEIVABLE	$	$	$

10	Accumulated Costs and Gross Income Recognized on Uncompleted Contracts	$	$	$
4	Inventories	$	$	$
5	Prepaid Insurance, Other Prepaid Expenses and Other Assets	$	$	$

TOTAL CURRENT ASSETS	$

6	Cash Surrender Value of Life Insurance	$	$
7	Property, Plant and Equipment Cost
Less Accumulated Depreciation	< >
OTHER ASSETS	Unamortized Organization Expenses
Deferred Charges and Other Assets
Other

TOTAL NONCURRENT ASSETS	$
TOTAL ASSETS	$

Statements based on reviews or compilations will not be acceptable.

NAME
AS OF	, 20

- LIABILITIES AND CAPITAL -

- LIABILITIES-

SCHEDULE NUMBER	CURRENT	NONCURRENT	TOTAL
8	NOTES PAYABLE
To Banks	$	$
a	To Officers, Directors, Stockholders, or Partners
b	To Affiliated Companies, Organizations, Partnerships, Joint Ventures, Etc.
Other Notes Not Included Above
TOTAL NOTES PAYABLE	$	$	$

9	ACCOUNTS PAYABLE
a	To Officers, Directors, Stockholders, or Partners (Including Wages, Salaries and Bonuses)	$	$
b	To Affiliated Companies, Organizations, Partnerships, Joint Ventures, Etc.
To Subcontractors
To Trade Suppliers
Others
TOTAL ACCOUNTS PAYABLE	$	$	$

ACCRUED EXPENSES
Wages, Salaries and Bonuses (Excluding 9a)	$	$
Taxes, Other Than Taxes On Income
Other
TOTAL ACCRUED EXPENSES	$	$	$

10	Deferred Credits from Billings and Advance Collections on Uncompleted Contracts	$	$	$
Taxes on Income
Other Liabilities: (Describe Below)
TOTAL CURRENT LIABILITIES	$
TOTAL NONCURRENT LIABILITIES	$
TOTAL LIABILITIES	$

- CAPITAL -

11	Individual or Partnership Capital	$
12	Capital Stock	Preferred Stock
Common Stock
13	Surplus	Capital or Paid-In Surplus
Retained Earnings
Less Treasury Stock at Cost
Other	< >

Are there ‘Notes to Balance Sheet’? Yes No If ‘yes’, attach copy to last page of this statement.	TOTAL CAPITAL	$
TOTAL LIABILITIES AND CAPITAL	$

ACCOUNTANT’S QUESTIONNAIRE

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

1	Is Property, Plant and Equipment valued at other than cost? Yes No If yes, explain the basis of valuation and indicate the amount in excess of cost for each classification.
2	Are any of the properties included under Property, Plant and Equipment held in joint Ownership? Yes No If yes, itemize and explain.
3	Are there any items of construction, plant and equipment and land not listed in Property, Plant and Equipment schedules which are held under lease or rental contracts, including those from related companies? Yes No If yes, list individual items covered..
4	Income tax returns are filed on a	year basis ending	Indicate method of tax
(month)	(day)
accounting Cash Accrual. Indicate method of accounting on the financial statements submitted herein Cash Accrual or Other. (Explain “other” below.)
5	Federal tax returns have been examined through	(year).
6	Were any Federal or State tax deficiencies Assessed or Proposed which are not reflected in this report? If so, explain.
7	Are there contingent liabilities which could affect the financial condition of this entity? Yes No If yes, explain fully.

8	(Individuals and Partnerships only) Are there any transactions reflected in the individual or partners capital accounts during the current reporting period which are not the result of (1) capital contributions, (2) net earnings, (3) withdrawals, or (4) net loss? Yes No If yes, explain fully.
9	(Individuals and Partnerships only) Is any part of the individuals or partners capital accounts the result of an increase in asset values due to appraisals? Yes No If yes, a schedule must be attached segregating the increase by asset types, i.e. land, buildings, equipment, etc. The appraisal values must be substantiated by current documentation attached to this statement. (Does not imply recognition by the Nebraska Department of Transportation.)
10	(Corporations only) Are any transactions reflected in the surplus accounts during the current reporting period which are not the result of (1) net income, (2) capital contributions, (3) dividends paid, or (4) net loss? Yes No If yes, explain fully.
11	(Corporations only) Are there any restrictions on the distribution of retained earnings? Yes No If yes, explain fully.
12	(Corporations only) Is any part of the total Capital the result of an increase in asset value due to appraisals? Yes No If yes, a schedule must be attached segregating the increase by asset type, i.e. land, buildings, equipment, etc. The appraisal values must be substantiated by current documentation attached to this statement. (Does not imply recognition by the Nebraska Department of Transportation.)
13	(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
14	(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
%
%
%
%

INDEPENDENT AUDITOR'S REPORT
FINANCIAL STATEMENT ONLY

STATE OF	DATE
COUNTY OF
I	, do affirm that I am a Certified Public Accountant
holding unrevoked Certificate No.	in the State of	, and License or
Permit No.	in the State of	, or a Public Accountant holding unrevoked
Certificate No.	in the State of Nebraska, and License or Permit No.
in the State of Nebraska, and I have signed this opinion as a member of the firm of
.

The balance sheet referred to below has been prepared solely for filing with the State of Nebraska, Department of Transportation and is not intended for any other purpose.

I/We have audited the accompanying balance sheet of *
as of	, 20 , as set forth on pages 5 and 6 herein including accompanying notes thereto.

This financial statement is the responsibility of the Company's management. My/Our responsibility is to express an opinion on this financial statement based on my/our audit.

I/We conducted our audit in accordance with accounting principles generally accepted in the United State of America. Those standards require that I/we plan and perform the audit to obtain reasonable assurance about whether the balance sheet is free of material misstatement. An audit includes examining, on a test basis, evidence supporting the amounts and disclosures in the balance sheet. An audit also includes assessing the accounting principles used and significant estimates made by management, as well as evaluating the overall balance sheet presentation. I/We believe that my/our audit of the balance sheet provides a reasonable basis for my/our opinion.

(ADD EXPLANATORY PARAGRAPH IF NECESSARY)

In my/our opinion, (except for the effects of
as discussed in the preceding paragraph), the balance sheet referred to above presents fairly, in all material respects,
the financial position of *
as of	, 20 , in conformity with accounting principles generally accepted in the
United States of America.

I/We have read and complied with all the instructions found on page 4 in the preparation of the financial part of this statement, and the balance sheet referred to in this report is not presented as a review or compilation.

* The name must agree with the name used on the Cover of this Statement and in the Affidavit.
Accounting Firm
If a substitute Independent Auditor's Report is submitted in lieu of this report, it must make reference to Pages 5 and 6 of Form R-123.
Address
Signature of Certified Public Accountant/Public Accountant (Must be signed by individual)
Area Code Telephone No.

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 ☐ 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.