Attachment 4 - Financial Questionnaire Sheet.pdf
PDF 223 KB Posted
- Attached to
- Front Desk Data Entry Contract
- Solicitation number
- FA452826TB02
About this file
This is a Responsibility Questionnaire and Financial Institution Reference Sheet form from the 5th Contracting Squadron at Minot Air Force Base, designed to evaluate contractor responsibility for federal contract award.
The Responsibility Questionnaire requires contractors to provide detailed information on up to three (3) previous customers or contracts, including the customer/contract name, address, point of contact name and telephone number, dates/years of performance, annual dollar value, and a description of services performed. This reference information enables the government to verify the contractor's past performance and business experience. The Financial Institution Reference Sheet instructs contractors to submit reference information for each banking institution where they maintain business accounts. The contractor section requires the company name, point of contact information, and financial institution details (name, POC, title, phone, and fax). Contractors must authorize the release of account information to the 5th Contracting Squadron. The financial institution section—to be completed only if the firm is selected as the potential awardee—requests average monthly balances in checking and savings accounts, current loan amounts, lines of credit, history of late payments or NSF occurrences, length of banking relationship, and credit rating. Financial information should be provided in ranges rather than specific figures. Both forms are required submission documents with the proposal to establish contractor financial stability and performance capability for contract award determination.
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Other files
| File | Type | Posted |
|---|---|---|
| Quote Sheet - Front Desk Admin Support.xlsx | XLSX spreadsheet | |
| SCA WD 2015-6025 Rev No 3.pdf | ||
| Front Desk Admin Support - Combined Synopsis and Solicitation.pdf | ||
| MFRC Front Desk Admin PWS (002).pdf |
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Text version
FA4528-26-TB02
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: ___________________________________
1558054260A Inserted Text
FA4528-25-Q-TA02
III. Name of Customer/Contract:___________________________________________
Address: ______________________________________________________________
Name of POC: _________________________________________________________
Telephone No: ________________________________________________
Dates/Years of Performance: ______________________________________________
Annual $ Value: ________________________________________________________
Services Performed/Additional Comments: ___________________________________
FA4528-25-Q-TA02
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
File details come from the government source that posted it. Updated .