36C25622R0030 EXHIBIT I-Financial Disclosure.docx
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- Attached to
- Z2FB--Biloxi MATOC-Seed Project Project #520-22-122 FCA Corrections BLDG 17 - 36C25622R0030
- Solicitation number
- 520-22-122
About this file
This document contains a financial disclosure questionnaire for federal contractors. The questionnaire is to be completed by an offeror and their financial institution for a Department of Veterans Affairs contract under Solicitation Number 520-22-122. The financial institution is asked to provide the offeror's account information, average balances, credit lines and limits, relationship and history with the bank, most recent credit rating and date, and the name and signature of the provider completing the form. Once completed, the offeror is to include the questionnaire in their response to the aforementioned VA solicitation for construction services related to Biloxi MATOC-Seed Project Project #520-22-122 FCA Corrections BLDG 17.
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Text version
FOR OFFICIAL USE ONLY
Source Selection Sensitive Information—See FAR 2.101 & 3.104 Project No. 520-22-122 FCA Corrections BLDG 17-MATOC Seed Project 36C25622R0030
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 16 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
FAR 2.101 and 3.104-5
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