S02 Att 10 Financial Disclosure 578-26-007.docx
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- Attached to
- Z1DZ--578-26-007-FY26 Network Cable Installation
- Solicitation number
- 36C25226R0013
About this file
This is a Financial Disclosure Questionnaire form (Attachment E) required as part of the proposal submission for solicitation 36C25226R0013. The form serves as a template to collect financial information from prospective contractors bidding on the VA's Indefinite Delivery Indefinite Quantity (IDIQ) contract for network cable installation at Edward Hines Jr. VA Hospital in Hines, Illinois. Section A must be completed by the offeror with their company information and an authorized representative's signature, while Section B is to be completed by the contractor's financial institution, providing details such as account type, average balance, line of credit information, relationship history with the bank, and credit rating information. The financial institution's responses are classified as source selection sensitive information and are prohibited from public disclosure under FAR 15.506.
The questionnaire is designed to assess the financial stability and capacity of contractors competing for this 100% Service-Disabled Veteran-Owned Small Business (SDVOSB) set-aside contract, which has a maximum aggregate value of $1 Million across all task orders over a five-year ordering period. Task orders are expected to range from $2,000 to $150,000, with the seed project valued between $100,000 and $150,000. Contractors must be certified SDVOSB concerns under the NAICS code 238210 (Wiring Installation) and maintain minimum bonding capacity for the contract's duration. The completed financial questionnaire must be returned to the Contracting Officer at Kristi.Kluck3@va.gov as part of the offeror's RFP response.
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SOL 36C25226R0013 Page 1 of 1
ATTACHMENT E
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: ______________________________ 578-26-007 IDIQ Replace Network Cabling
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