Attachment 4_Financial Responsibility Questionnaire.docx

FA0021-16-R-0040

Attachment 4 7 September 2016

FA002121R0001

Attachment 4

FINANCIAL RESPONSIBILTY QUESTIONNAIRE

Contractor Information:

Name: ________________________________________________________________________

Address: ______________________________________________________________________

Point of Contact (POC): _________________________________________________________

Telephone: ____________________________________________________________________

E-mail: _______________________________________________________________________

FINANCIAL INSTITUTION:

The above named contractor is currently competing for a contract to perform Intelligence Support and Intelligence Surveillance and Reconnaissance Processing, Exploitation and Dissemination (ISR-PED for the Air Force Special Operations Command (AFSOC) Intelligence Directorate at Hurlburt Field, FL. As part of the financial responsibility determination required by FAR 9.104-1, please provide the following information to be included in the contractor’s proposal submission. This information wll be kept secure and only those who have a need to know will view this document. Any questions concerning this form can be directed to the Contracting Officer, Mr. Shawn Edwards, telephone: (850) 884-7829, E-mail: shawn.edwards.14@us.af.mil. Your assistance is greatly appreciated!

Financial Institution Name: _______________________________________________________

Financial Institution Address: _____________________________________________________

Point of Contact (POC): __________________________________________________________

POC Title: _____________________________________________________________________

POC Phone: ___________________________________________________________________

POC E-mail Address: ____________________________________________________________

QUESTIONS:

1. How long has the contractor’s account(s) been open? _________________________________

2. What is the average balance in the account? _________________________________________ (State high 6 figure, low 7 figure, etc.)

3. Does the customer have a credit line available? _____________________________________

a. If so, what amount of credit is available? ________________________________________ (State high 6 figure, low 7 figure, etc.)

4. Is the customer’s account (s) in good standing? ______________________________________

5. Does the institution feel comfortable continuing to support this customer in their business endeavors? ____________________________________________________________________

6. Additional remarks, if any: _____________________________________________________

POC Signature: _______________________________________ Date: ___________________