Construction of Samudaya Bhavana at Hosa Nelludi, Ramasagara, Hirejayiganoor Villages and Construction of Golla & Uppara Samudaya Bhavana at Kurugodu Town and Gangamatha Samudaya Bhavana at Kampli Town, Under 4059-CMIDP Grant for the Year 2025-26.

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

Attach Chartered Accountant's Yearwise Statements.

Note : Documents shall be attested by the Notary or Government Gazetted and original documents to be submitted at the time of opening of Technical bid for verification (Original documents shall scan and uploaded). The IT Returns statement shall also be scanned and uploaded.

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

Note : Documents shall be attested by the Notary or Government Gazetted and original documents to be submitted at the time of opening of Technical bid for verification (Original documents shall be scanned and uploaded).

Quantities of work executed as prime contractor (in the same name) during the last five years i.e., from 2020-21 to 2024-25

Year Name of Work Name of Employer Quantity of work performed Remarks(Indicate contract reference)

Earth work excavation in Cum Sub base and shoulders (Gravel/murrum) in Cum Wet mix macadam in Cum Bituminous Macadam in Cum Mix seal surfacing in Sqm Plain /Reinforced Cement concrete in Cum Size Stone Masonry in cum

Attach Workdone Certificate for each work indicated above, obtained from the Competent Authority not below the rank of Executive Engineer or equivalent.

Note : Documents shall be attested by the Notary or Government Gazetted. The Original documents shall

scanned and uploaded. At the time of opening of the Technical Bid, submit the original documents for

Physical verification.

FORMAT FOR WORK DONE CERTIFICATE TO BE OBTAINED FROM COMPETENT AUTHORITY

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 * : 2021

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

Earthwork Physical in cum :

Financial in lac :

Formation of Road embankment Physical in cum :

Financial in lac :

Metalling Physical in cum :

Financial in lac :

Mix-seal Surfacing Physical in Sqm :

Financial in lac :

Others (Pl specify) Physical is cum/sqm :

Financial in lac :

Others (Pl specify) Physical :

Financial in lac :

Progress * : 2022

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

Earthwork Physical in cum :

Financial in lac :

Formation of Road embankment Physical in Quintal :

Financial in lac :

Metalling Physical in cum :

Financial in lac :

Mix-seal Surfacing Physical in Sqm :

Financial in lac :

Others (Pl specify) Physical is cum/sqm :

Financial in lac :

Others (Pl specify) Physical :

Financial in lac :

Progress * : 2023

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

Earthwork Physical in cum :

Financial in lac :

Formation of Road embankment Physical in Quintal :

Financial in lac :

Metalling Physical in cum :

Financial in lac :

Mix-seal Surfacing Physical in Sqm :

Financial in lac :

Others (Pl specify) Physical is cum/sqm :

Financial in lac :

Others (Pl specify) Physical :

Financial in lac :

Progress * : 2024

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

Earthwork Physical in cum :

Financial in lac :

Formation of Road embankment Physical in Quintal :

Financial in lac :

Metalling Physical in cum :

Financial in lac :

Mix-seal Surfacing Physical in Sqm :

Financial in lac :

Others (Pl specify) Physical is cum/sqm :

Financial in lac :

Others (Pl specify) Physical :

Financial in lac :

Progress * : 2025

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

Earthwork Physical in cum :

Financial in lac :

Formation of Road embankment Physical in Quintal :

Financial in lac :

Metalling Physical in cum :

Financial in lac :

Mix-seal Surfacing Physical in Sqm :

Financial in lac :

Others (Pl specify) Physical is cum/sqm :

Financial in lac :

Others (Pl specify) Physical :

Financial in lac :

Progress * : 2026

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

Earthwork Physical in cum :

Financial in lac :

Formation of Road embankment Physical in Quintal :

Financial in lac :

Metalling Physical in cum :

Financial in lac :

Mix-seal Surfacing Physical in Sqm :

Financial in lac :

Others (Pl specify) Physical is cum/sqm :

Financial in lac :

Others (Pl specify) Physical :

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 :

* Monthwise progress shall be furnished seperately.

Date: (Authorised Signatory)

Address for correspondence:

Note : Documents shall be attested by the Notary or Government Gazetted and original documents to be submitted at the time of opening of Technical bid for verification. Originals shall sacnned and uploaded.

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 2021 Remarks (Indicate contract reference)

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

Earthworks in cum Physical

Formation of Road embankment in cum Physical

Metalling in Cum Physical

Asphalting (20 mm thick MSS) in sqm Physical

Others Specify Details Physical

Earthworks in cum Physical

Formation of Road embankment in cum Physical

Metalling in Cum Physical

Asphalting (20 mm thick MSS) in sqm Physical

Others Specify Details Physical

Earthworks in cum Physical

Formation of Road embankment in cum Physical

Metalling in Cum Physical

Asphalting (20 mm thick MSS) in sqm Physical

Others Specify Details Physical

Earthworks in cum Physical

Formation of Road embankment in cum Physical

Metalling in Cum Physical

Asphalting (20 mm thick MSS) in sqm Physical

Others Specify Details Physical

Earthworks in cum Physical

Formation of Road embankment in cum Physical

Metalling in Cum Physical

Asphalting (20 mm thick MSS) in sqm Physical

Others Specify Details Physical

Earthworks in cum Physical .

Formation of Road embankment in cum Physical

Metalling in Cum Physical

Asphalting (20 mm thick MSS) in sqm Physical

Others Specify Details Physical

Note : Documents shall be attested by the Notary or Government Gazetted and original documents to be submitted at the time of opening of Technical bid for verification. Originals shall sacnned and uploaded.

Information on works which are yet to be completed.

(EXISTING COMMITMENTS AND ON-GOING WORKS)

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 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

Note : Documents shall be attested by the Notary or Government Gazetted and original documents to be submitted at the time of opening of Technical bid for verification. Originals shall sacnned and uploaded.

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.

Note : Documents shall be attested by the Notary or Government Gazetted and original documents to be submitted at the time of opening of Technical bid for verification. Originals shall sacnned and uploaded.

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.

Note : Documents shall be attested by the Notary or Government Gazetted and original documents to be submitted at the time of opening of Technical bid for verification. Originals shall sacnned and uploaded.

List of Machineries Required

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

No. Capacity Number/Capacity Age/ Condition

Note : Documents shall be attested by the Notary or Government Gazetted and original documents to be submitted at the time of opening of Technical bid for verification. Originals shall sacnned and uploaded.

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. …………....../- (inwards) .................................................................... ..... to meet the working capital requirements for executing the above contract

Name of the Bank, Senior Bank Manger

Note : Documents shall be attested by the Notary or Government Gazetted and original documents to be submitted at the time of opening of Technical bid for verification. Originals shall sacnned and uploaded.

Information on litigation in which the Tenderer is involved:

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

Note : Documents shall be attested by the Notary or Government Gazetted and original documents to be submitted at the time of opening of Technical bid for verification. Originals shall sacnned and uploaded.