S02 AttC Financial Disclosure 585-21-111 Upgrade Nurse Call.pdf
PDF 136 KB Posted
- Attached to
- Z1DA--585-21-111 Upgrade Nurse Call System at the Oscar G Johnson VA Medical Center in Iron Mountain, MI
- Solicitation number
- 36C25224B0003
About this file
This document contains a financial disclosure questionnaire and details of a related federal contract opportunity. The financial disclosure questionnaire is to be completed by a prospective contractor and submitted to a financial institution, which will then provide comments on the contractor's financial status, account details, credit ratings, and relationship with the bank. The federal contract opportunity is a solicitation from the Department of Veterans Affairs to upgrade the nurse call system at the Oscar G Johnson VA Medical Center in Iron Mountain, Michigan. The solicitation number is 36C25224B0003. Responses are due by the date specified in the solicitation. The award will be made after evaluation of responses received by the due date.
View the file
Other files
Show all 14
On GovTribe
Work with this file
- Download the original file
- Contacts named in this file
- Similar government files
- Ask GovTribe AI about this file
Text version
SOL 36C252240003, ATTACHMENT C
Project 585-21-111 Upgrade Nurse Call System Page 1 of 1
Financial Disclosure Questionnaire
OFFEROR INSTRUCTIONS: Section A shall be completed by Offeror and submitted to
Financial Institution requesting they complete and return to Contracting Officer
(Kristi.Kluck3@va.gov)
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:
SECTION B - 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.
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: ______________________________ mailto:Kristi.Kluck3@va.gov
File details come from the government source that posted it. Updated .