Attachment 4- Contractor Determination of Responsibility FLM.doc

Attachment 4

SEQ CHAPTER \h \r 1CONTRACTOR DETERMINATION OF RESPONSIBILITY

(FINANCIAL INFORMATION)

TO BE COMPLETED BY CONTRACTOR

Solicitation Information: Offeror:

Date:

Solicitation: 15JA05-20-R-00000058 USAO- Middle Northern District of Florida

Requirement: Grand Jury and Deposition Court Reporting Services

Contract Amount: Estimated Value $ (WITHOUT 6 MONTH $ VALUE) Financial Reference Contacted:

Financial Institution Name & Address:

Financial Institution Phone:

Financial Institution Contact:

Name/ Title/ Email Address (all mandatory information):

TO BE COMPLETED BY FINANCIAL INSTITUTION:

Questions:

1. When was the account opened? _______________________________________

2. How is the account maintained?

(Excellent Fair Poor)

3. What is the average monthly balance?

(High

Medium Low)

4. Number of figures of balance (Example: If the company has $1,000.00, the number of figures would be a 4). (7 6 5 4 3 2 1)

5. Any account overdrafts? (Yes) (No)

6. Has offeror ever filed for bankruptcy? (Yes) (No)

7. Is the credit standing sufficient to obtain loans from your bank? (Yes) (No)

8. Comments/Further Explanations of Items Above: ____________________________________________________________________________________________________________________________________________________________

SOLICITATION 15JA05-20-R-00000058 MIDDLE DISTRICT OF FLORIDA