36S79718R0007-027.docx

ATTACHMENT C

RFP 36S79718R0007

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:

Name & Signature of the Person Authorized to request financial information:

FINANCIAL INSTITUTION INSTRUCTIONS: The Department of Veterans Affairs (VA), National Acquisition Center 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: ______________________________