Attachment 4-Contractor Responsibility-Financial Disclosures.docx

FA301620Q0120 Attachment 4

FA301620Q0120 Attachment 4

FA301620Q0120

JBSA FSH ICIDS IV Alarm Maintenance Support Services Attachment 4

CONTRACTOR RESPONSIBILITY PACKAGE

The following documents and related instructions for completion have been provided for use in the Contractor Responsibility determination in accordance with FAR Part 9.

1) Financial Disclosure Release Authorization. The quoter is instructed to complete, sign and submit this form as part of its proposal submission so the Government may request information from at least one current financial institution or lender.

2) Financial Information. This form is provided as a sample so that quoters may see what information will be asked of the financial institution. This form does not get submitted as part of the quote.

Contractor responsibility documents are considered administrative submissions and do not count toward technical or pricing page limitations, if any.

FINANCIAL DISCLOSURE RELEASE AUTHORIZATION

FA301620Q0120

JBSA FSH ICIDS IV Alarm Maintenance Support Services

FINANCIAL INSTITUTION NAME: __________________________

FINANCIAL INSTITUTION ADDRESS:

FINANCIAL INSTITUTION POINT OF CONTACT (POC): _________________________________

FINANCIAL INSTITUTION TELEPHONE NUMBER: _______________________________

FINANCIAL INSTITUTION POC EMAIL:

TYPE OF ACCOUNT (checking/savings/etc.): _________________________________

I, __________________________ authorize release of the information requested on the (Insert name of contractor’s representative. Please print.) attached form(s) to the 502d Contracting Squadron, Joint Base San Antonio-Randolph.

All information provided will be safeguarded in accordance with procedures outlined in the Privacy Act of 1974 and DOD 5400.11R.

Signature

Title

Date

Company Name

FINANCIAL INFORMATION

FA301620Q0120

JBSA FSH ICIDS IV Alarm Maintenance Support Services (To be completed by financial institution and returned directly to 502 CONS Contracting)

Contractor Name:

Type of Account (checking/savings/etc.):

Contractor's Financial Institution: Financial Institution's Phone:

Contractor's Financial Institution Point of Contact:

1. How long has the contractor had an account with your financial institution?

2. What is the contractor's current status with the financial institution? (e.g., poor, fair, good, excellent, outstanding) ___________________.

Any additional comments?

3. Has the company's accounting practices been satisfactory (yes or no)? ________.

If no, why?

4. How many accounts and what types of accounts does the company have with the institution? _______

a. _______________________________________________________

b. _______________________________________________________

c. _______________________________________________________

5. What is the company's current operational balance (e.g., low, moderate, or high--five, six figure, etc.) ?

6. Does the contractor have a line of credit (yes or no)? ________ If yes, is the line of credit authorized Low, moderate, or high--five, six figure, etc.?

7. Based on the contractor's financial history, current status, and the magnitude of this project (six figures or more annually), do you feel the contractor will be able to perform his financial obligation (yes or no)?

If no, why (in terms that will not violate what you as a financial institution are allowed to disclose)?

Signature Date

Title The information herein is For Official Use Only (FOUO) which must be protected under the Freedom of Information Act of 1966 and Privacy Act of 1974, as amended. Unauthorized disclosure or misuse of this PERSONAL INFORMATION may result in criminal and/or civil penalties”.