ATTACHMENT_5--Contractor_Financial_Disclosure_Questionaire_(1_page).docx
DOCX document 18 KB Posted
- Attached to
- Greenstone--ND/SD CONSTRUCTION MATOC
- Solicitation number
- 36C26318R0063
About this file
This solicitation notice is for a Multiple Award Task Order Contract for construction services within the North and South Dakota region for the Department of Veterans Affairs Veterans Integrated Service Network 23. The solicitation will seek to make multiple awards of Indefinite-Delivery Indefinite-Quantity contracts for maintenance, repair, alteration, and new construction services for VA facilities including Fargo VA Health Care System, VA Black Hills Health Care System, Royal C. Johnson Veterans Memorial Medical Center and their associated clinics. The construction MATOC will have a maximum value of $70 million over a five year ordering period. This is a 100% set-aside for Service Disabled Veteran Owned Small Businesses. Responses are due at a date to be determined upon solicitation release on Federal Business Opportunities at www.fbo.gov. Interested parties must register to receive amendments and be listed on the interested vendors list on this site.
36C26318R0063 ATTACHMENT 5--Contractor Financial Disclosure Questionaire (1 page).docx
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Indefinite Delivery Indefinite Quantity (IDIQ) Contracts Solicitation 36C26318R0063
Solicitation Attachment 5 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 23 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 5 FAR 2.101 and 3.104-5
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