36C25218R0104-004.docx
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- Solicitation number
- 36C25218R0104
About this file
This notice provides details for a Multiple Award Task Order Contract (MATOC) solicitation for construction services. The Department of Veterans Affairs intends to award multiple Indefinite-Delivery Indefinite-Quantity contracts valued between $2,000 to $2,000,000 each for maintenance, repair, alteration, and new construction projects at its Clement J. Zablocki VA Medical Center in Milwaukee, Wisconsin. The total value of all task orders awarded under this MATOC shall not exceed $50 million over five years. The primary work will include general construction as well as incidental work such as carpentry, paving, roofing, plumbing, electrical and mechanical. The North American Industry Classification System code is 236220. The solicitation number is 36C25218R0104 and will be issued on or around February 5, 2018 via the Federal Business Opportunities website. This acquisition is reserved solely for Service-Disabled Veteran-Owned Small Businesses certified in the Vendor Information Pages database.
36C25218R0104 S02 SOL-Att-03 Financial Disclosure Questionnaire.docx
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Multiple Award Task Order Contract (MATOC) 36C25218R0104
Solicitation Attachment 3 Financial Disclosure Questionnaire
OFFEROR INSTRUCTIONS: Section A shall be completed by Offeror and submitted to Financial Institution requesting they complete and return to Offeror and included in the RFP offer.
SECTION A:
Prospective Contractor for which information is being requested:
| Contractor Name: | ___________________________________________ | |||
| Address: | ___________________________________________ | |||
| ___________________________________________ | ||||
| Phone Number: | ___________________________________________ | |||
| e-mail: | ___________________________________________ |
Name & Signature of the Person Authorized to request financial information:
FINANCIAL INSTITUTION INSTRUCTIONS: The Department of Veterans Affairs, Network Contracting Office 12 is considering the firm listed above for award of a VA contract. In order to be responsive to VA’s needs, it is requested that you complete this questionnaire and return to the Offeror such that it is included with their RFP offer. Your comments are considered Source Selection Sensitive; therefore, you are advised that Federal Acquisition Regulation FAR-15.506 prohibits the release of the names of individuals providing reference information about Offeror’s financial status.
SECTION B:
Banking Institution: _________________________________________
Account number: ______________ Type of account:_______ Average balance:__________
Do they have a Line of Credit? [ ] Yes [ ] No
What is their limitation: ________________________ Unused Balance: _________________
Relationship with the bank: [ ] Outstanding [ ] Satisfactory [ ] Other: __________________
How long have they been a client: ______________________________
What is their most recent credit rating: ______________________________
Date of most recent credit rating: ______________________________
Credit rating prepared by: ______________________________
Signature of Provider/Title: ______________________________
Date: ______________________________
SOURCE SELECTION SENSITIVE Page 1 of 1 Attachment 3 FAR 2.101 and 3.104-5
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