ATTACH 4 - Financial Worksheet_Sample.pdf

Attachment 4 FA670320B0003

FINANCIAL INSTITUTION REFERENCE SHEET

Instructions to Contractor: Please fill out and return a reference sheet for each financial institution that you have a business account with. This sheet may be sent to the banking institution/s in regards to a determination of contractor responsibility as part of the evaluation for solicitation number

FA670320B0003

TO BE FILLED OUT BY CONTRACTOR:

Company’s Name: ___________________________________________ Point of Contact (POC) Name: _________________________________ POC Phone Number: _________________________________________

INSTITUTION NAME: ______________________________________

POC Name: ________________________________________________ POC Title: _________________________________________________ POC Phone Number: _______________Fax Number: ______________

I give permission for the following information regarding my account(s) at your institution to be released to representatives of the 94th Contracting Flight, Dobbins ARB, GA.

Printed Name/Title Signature/Date

TO BE FILLED OUT BY FINANCIAL INSTITUTION:

Please give amounts as a range – i.e., low four figures, mid six figures, etc.

Average monthly balance in checking: ____________________________ Average monthly balance in savings: _____________________________ Amount of any current loans: ___________________________________ Amount of any lines of credit: __________________________________ Any late payments of NSFs: ____________________________________ How long with this institution: __________________________________ Credit rating with this institution: ________________________________

I verify that the information provided above is current as of _____________________________

Name/Title Signature/Date