S02 Sol R0036 AttD Financial Disclosure 578-25-003.docx
DOCX document 18 KB Posted
- Attached to
- Z1DA--578-25-003 Renovate Elevators B200 (Construction) at the Hines VA Hospital in Hines, IL
- Solicitation number
- 36C25225R0036_3
About this file
This document is a Financial Disclosure Questionnaire for a Department of Veterans Affairs (VA) contract opportunity for elevator renovation at the Hines VA Hospital in Hines, Illinois. The solicitation (36C25225R0036) involves replacing elevators in Building 200, with the document designed to collect financial information from potential contractors through a two-section form. Section A requires the prospective contractor to complete identifying information and authorize a financial institution to provide confidential financial details, while Section B is completed by the banking institution to disclose account details, credit ratings, banking relationship status, and credit line information. The financial disclosure is part of the source selection process for the VA Network Contracting Office 12, with the information to be submitted alongside the Request for Proposal (RFP) and treated as source selection sensitive information.
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Text version
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: | __________________________________________________________ | |
| __________________________________________________________ | ||
| __________________________________________________________ |
Name & Signature of the Person Authorized to request financial information: ______________________________________________
| Phone Number: | __________________________________________________________ | |
| e-mail: | __________________________________________________________ |
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 - FINANCIAL INSTITUTION INSTRUCTIONS:
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: ______________________________
Solicitation 36C25225R0036 Project 578-25-003 Replace Elevators in Bldg 200 Attachment D – Financial Disclosure Page 1 of 1
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