Attachment 4 - Financial Questionnaire Sheet.pdf

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Attached to
Integrated Solid Waste Management
Solicitation number
FA4528-26-Q-DH01
Issued by

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This document is a Responsibility Questionnaire (Attachment 4) for solicitation FA4528-25-Q-DH01, issued by the 5th Contracting Squadron at Minot Air Force Base in North Dakota. The document contains two key sections: a Customer/Contract Reference section and a Financial Institution Reference Sheet. In the first section, offerors are required to provide details about up to three previous customer contracts, including customer names, addresses, points of contact, telephone numbers, performance dates, annual dollar values, and services performed.

The Financial Institution Reference Sheet requires contractors to provide information about their business banking relationships, including company and institution details. If selected as a potential awardee, the contractor's bank will be asked to complete a confidential section verifying financial details such as average account balances, current loans, lines of credit, payment history, and credit rating. The form is designed to help the contracting squadron assess the financial responsibility and past performance capabilities of potential contractors during the solicitation evaluation process.

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FA4528-25-Q-DH01

Attachment 4

RESPONSIBILITY QUESTIONNAIRE

The following information is needed to help evaluate and determine your company responsible. Please complete the following items and submit with your proposal:

A. The names of up to three (3) customers/contracts that you have held or done business with, to include points of contact and phone numbers.

I. Name of Customer/Contract:_____________________________________________

Address: ______________________________________________________________

Name of POC: _________________________________________________________

Telephone No: _________________________________________________________

Dates/Years of Performance: ______________________________________________

Annual $ Value: ________________________________________________________

Services Performed/Additional Comments: ___________________________________

II. Name of Customer/Contract:____________________________________________

Address: ______________________________________________________________

Name of POC: _________________________________________________________

Telephone No: _________________________________________________________

Dates/Years of Performance: ______________________________________________

Annual $ Value: ________________________________________________________

Services Performed/Additional Comments: ___________________________________

III. Name of Customer/Contract:___________________________________________

Address: ______________________________________________________________

Name of POC: _________________________________________________________

Telephone No: ________________________________________________

Dates/Years of Performance: ______________________________________________

Annual $ Value: ________________________________________________________

Services Performed/Additional Comments: ___________________________________

FINANCIAL INSTITUTION REFERENCE SHEET

Instructions to Contractor: Include with your proposal 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 award of this solicitation.

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 5 th

Contracting Squadron, Minot AFB, North Dakota.

Name/Title Signature/Date

DO NOT HAVE THIS SECTION FILLED OUT. IF YOUR FIRM IS SELECTED AS THE POTENTIAL

AWARDEE, THIS FORM WILL BE SENT TO YOUR BANKING INSTITUTION FOR COMPLETION.

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 or NSF’s? ______________

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

I Name of CustomerContract:
Address:
Name of POC:
Telephone No:
DatesYears of Performance:
Annual Value:
Services PerformedAdditional Comments 1:
Services PerformedAdditional Comments 2:
Services PerformedAdditional Comments 3:
Services PerformedAdditional Comments 4:
Services PerformedAdditional Comments 5:
II Name of CustomerContract:
Address_2:
Name of POC_2:
Telephone No_2:
DatesYears of Performance_2:
Annual Value_2:
Services PerformedAdditional Comments 1_2:
Services PerformedAdditional Comments 2_2:
Page 2 1:
Page 2 2:
Page 2 3:
III Name of CustomerContract:
Address_3:
Name of POC_3:
Telephone No_3:
DatesYears of Performance_3:
Annual Value_3:
Services PerformedAdditional Comments 1_3:
Services PerformedAdditional Comments 2_3:
Services PerformedAdditional Comments 3_2:
Services PerformedAdditional Comments 4_2:
Services PerformedAdditional Comments 5_2:
COMPANYS NAME:
Point of Contact POC Name:
POC Phone Number:
INSTITUTION NAME:
POC name:
POC title:
POC phone number:
fax number:
NameTitle:
DO NOT HAVE THIS SECTION FILLED OUT IF YOUR FIRM IS SELECTED AS THE POTENTIAL:
Average monthly balance in checking:
Average monthly balance in savings:
Amount of any current loans:
Amount of any lines of credit:
Any late payments or NSFs:
How long with this institution:
Credit rating with this institution:
I verify that the information provided above is current as of:
NameTitle_2:

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