Attachment 4. Determination of Financial Responsibility.pdf

This is a Determination of Financial Responsibility Questionnaire form issued by the Federal Emergency Management Agency (FEMA), Region IV, located in Atlanta, Georgia. The form is designed to assess the financial capability and responsibility of vendors or offerors seeking to contract with FEMA.

The questionnaire is divided into two distinct sections: a banking institution section and a vendor authorization section. The banking institution completes the upper portion by providing information about the vendor's banking relationship, including the bank name, contact phone number, name of the bank representative, and signature of the representative. The banking institution must also document how long the vendor has maintained a banking customer relationship and provide a professional assessment regarding whether there are any reasons the bank would decline to provide the vendor with a loan. The vendor completes only the authorization section at the bottom, wherein an authorized representative (identified by name and title) certifies their company name and authorizes the release of the banking information provided by their financial institution directly to FEMA at the Atlanta regional office. The form requires the vendor representative's signature and date of authorization.