CONSTRUCTION OF CC ROAD AND DRAINAGE IN SC COLONY IN MUCHAKANDI VILLAGE OF BAGALKOTE TALUK OF BAGALKOTE DISTRICT. UNDER 4059-80-051-0-60-422 CMIDP SCP FOR THE YEAR 2025-26(Reserved for ST)

Financial Year Total value of Civil Engineering works executed and payments received in the last five years (in Rs.lakhs)

Billed upto date during 2024-25

Attach Chartered Accountant's Yearwise Statements

Work executed as prime contractor (in the same name) on works of similar nature during the five years specified)

Project Name Name & Address of the Employer Name of Work Contract Number Value of contract Rs. Lakhs Date of markout / Date of Handing over of site Specified period of completion (including/ excluding Monsoon) Actual date of completion Remarks (appreciation letter received for early completion or reasons, if there is delay in completion)

Attach Workdone Certificate for each work indicated above, in Format 3, obtained from the Competent Authority.

FORMAT FOR WORK DONE CERTIFICATE TO BE OBTAINED FROM COMPETENT AUTHORITY

This is to certify that M/s Sri / Smt.

has executed / is executing (strike off which ever is not applicable) the work of..

in this Organisation. The details of the work is as under :

1 Name of the Project

2 Name of the Work

3 Contract Amount

4 Date of signing the Agreement

5 Date of handing over of the Site

6 Progress 2017

January February March April May June July August September October November December

Earthwork Physical in Cum

Financial in lac

GSB Physical in Cum

Financial in lac

WBM/WMM Physical in Cum

Financial in lac

Asphalting (Including DBM/BC/BM/SDBC) Physical in Cum

Financial in lac

6 Progress 2018

January February March April May June July August September October November December

Earthwork Physical in Cum

Financial in lac

GSB Physical in Cum

Financial in lac

WBM/WMM Physical in Cum

Financial in lac

Asphalting (Including DBM/BC/BM/SDBC) Physical in Cum

Financial in lac

PCC/RCC Physical in Cum

Financial in lac

TMT Steel Physical in Tonne

Financial in lac

6 Progress 2019

January February March April May June July August September October November December

Earthwork Physical in Cum

Financial in lac

GSB Physical in Cum

Financial in lac

WBM/WMM Physical in Cum

Financial in lac

Asphalting (Including DBM/BC/BM/SDBC) Physical in Cum

Financial in lac

PCC/RCC Physical in Cum

Financial in lac

TMT Steel Physical in Tonne

Financial in lac

6 Progress 2020

January February March April May June July August September October November December

Earthwork Physical in Cum

Financial in lac

GSB Physical in Cum

Financial in lac

WBM/WMM Physical in Cum

Financial in lac

Asphalting (Including DBM/BC/BM/SDBC) Physical in Cum

Financial in lac

PCC/RCC Physical in Cum

Financial in lac

TMT Steel Physical in Tonne

Financial in lac

6 Progress 2021

January February March April May June July August September October November December

Earthwork Physical in Cum

Financial in lac

GSB Physical in Cum

Financial in lac

WBM/WMM Physical in Cum

Financial in lac

Asphalting (Including DBM/BC/BM/SDBC) Physical in Cum

Financial in lac

PCC/RCC Physical in Cum

Financial in lac

TMT Steel Physical in Tonne

Financial in lac

7 Stipulated Period of Completion (including monsoon)

8 Prescribed Date of completion.

9 Actual Date of Completion/Probable Date of Completion.

10 Cost of balance work (if work is in progress)

11 Reasons if any for delay in completion, if work completion is delayed

12 Penalty if any imposed

13 Any other information.

* Monthlywise progress shall be furnished seperately.

Place : (Authorised Signatory)

Address for correspondence:

Monthly Physical and Financial Progress Achieved in all Contracts which are referred to in Format 3

Names of Works Item of work Names of Employers 2017

January February March April May June July August September October November December Remarks (Indicate contract reference)

Earthwork Physical in Cum

Financial in lac

GSB Physical in Cum

Financial in lac

WBM/WMM Physical in Cum

Financial in lac

Asphalting (Including DBM/BC/BM/SDBC) Physical in Cum

Financial in lac

PCC/RCC Physical in Cum

Financial in lac

TMT Steel Physical in Tonne

Financial in lac

Names of Works Item of work Names of Employers 2018

January February March April May June July August September October November December Remarks (Indicate contract reference)

Earthwork Physical in Cum

Financial in lac

GSB Physical in Cum

Financial in lac

WBM/WMM Physical in Cum

Financial in lac

Asphalting (Including DBM/BC/BM/SDBC) Physical in Cum

Financial in lac

PCC/RCC Physical in Cum

Financial in lac

TMT Steel Physical in Tonne

Financial in lac

Names of Works Item of work Names of Employers 2019

January February March April May June July August September October November December Remarks (Indicate contract reference)

Earthwork Physical in Cum

Financial in lac

GSB Physical in Cum

Financial in lac

WBM/WMM Physical in Cum

Financial in lac

Asphalting (Including DBM/BC/BM/SDBC) Physical in Cum

Financial in lac

PCC/RCC Physical in Cum

Financial in lac

TMT Steel Physical in Tonne

Financial in lac

Names of Works Item of work Names of Employers 2020

January February March April May June July August September October November December Remarks (Indicate contract reference)

Earthwork Physical in Cum

Financial in lac

GSB Physical in Cum

Financial in lac

WBM/WMM Physical in Cum

Financial in lac

Asphalting (Including DBM/BC/BM/SDBC) Physical in Cum

Financial in lac

PCC/RCC Physical in Cum

Financial in lac

TMT Steel Physical in Tonne

Financial in lac

Names of Works Item of work Names of Employers 2021

January February March April May June July August September October November December Remarks (Indicate contract reference)

Earthwork Physical in Cum

Financial in lac

GSB Physical in Cum

Financial in lac

WBM/WMM Physical in Cum

Financial in lac

Asphalting (Including DBM/BC/BM/SDBC) Physical in Cum

Financial in lac

PCC/RCC Physical in Cum

Financial in lac

TMT Steel Physical in Tonne

Financial in lac

* Monthlywise progress shall be furnished seperately.

Place : CONTRACTOR

Address for correspondence:

Information on works which are yet to be completed.

Project Name Name & Address of the Employer Name of Work Contract Number Value of contract Rs.Lakhs Date of Markout / Date of Handing over of site Speified period of completion (including / excluding Monsoon) Cost of balance works remaining Rs.in Lac Probable date of completion.

Attach Certificate for each work indicated above, in Format 3, obtained from the Competent Authority

Information of the works for which Tender acceptance letters are received.

Project Name Name & Address of the Employer Name of Work Tendered Amount in Rs. Lac Specified period of completion (including / excluding Monsoon) Probable Date of Handing over of site.

Attach letters of Acceptance received.

Information of the works for which Tenderer has submitted Tender.

Project Name Name & Address of the Employer Name of Work Amount put to Tender in Rs.lac Specified period of completion (including / excluding Monsoon) Prescribed last date of submission of tender Probable date of decision on the Tender Remarks if any.

List of Machinery

Item of Equipment Requirement Owned / Hired / Leased Owner / Hired / Lease and available Remarks

No. Capacity Number / Capacity Age / Condition

BANKER’S CERTIFICATE

This is to certify that M/s. ________________________________________________ is a reputed company with a good financial standing. If the contract for this work, namely ________________________________________________________ (name of the work) is awarded to the above firm, we shall be able to provide overdraft/credit facilities to the extent of Rs._______________________________ to meet the working capital requirements for executing the above contract

Signature of the Bank Manger

along with Seal

Information on litigation in which the Tenderer is involved:

Other Party/Parties Employer Details of Dispute Amount involved Remarks showing Present Status