36C25218R0105-005.docx
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- Attached to
- Southern Tier Construction Multiple Award Task Order Contrac (MATOC) Federal contract opportunity
- Solicitation number
- 36C25218R0105
About this file
This document contains a pre-solicitation notice for a Multiple Award Task Order Contract for construction services. The Department of Veterans Affairs intends to award multiple IDIQ contracts valued between $2,000 and $5,000,000 each, with an aggregate value not to exceed $120 million over five years. The contracts will provide maintenance, repair, alteration, and construction services for four VA medical centers in Illinois and Indiana. Services will include general construction as well as carpentry, asphalt, roofing, excavation, renovation, mechanical, electrical, plumbing, painting and other construction work. Task order solicitations will be competitively issued to all selected MATOC contractors. The acquisition is reserved as a 100% set-aside for Service-Disabled Veteran-Owned Small Businesses. The solicitation is expected to be issued on or about May 1, 2018.
36C25218R0105 S02 SOL-Att-03 Financial Disclosure Questionnaire.docx
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Text version
Multiple Award Task Order Contract (MATOC) 36C25218R0105
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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