Attachment 4-Responsibility Questionnaire ZQEL 24-0012.docx
DOCX document 22 KB Posted
- Solicitation number
- FA665624B0003
About this file
This document is a Responsibility Questionnaire, which is used to help evaluate and determine a company's responsibility for a federal contract opportunity. The questionnaire requests information about the company's suppliers, including points of contact and phone numbers, as well as a financial institution reference sheet that provides details on the company's banking accounts and financial standing. This information is used to assess the company's ability to successfully perform the contract.
The related federal contract opportunity is for road/parking striping, catch basin replacement, and asphalt repair at the 910 Airlift Wing (AFRC), Youngstown Air Reserve Station in Ohio. The solicitation is a 100% HUBZone Small Business set-aside, with a single award to be made. The project consists of three line items, including restriping roads and parking areas, replacing a catch basin, and removing and replacing a section of asphalt. The total contract performance period is 90 calendar days, and the contract type is Firm-Fixed Price. The estimated value of the project is between $100,000 and $250,000. The NAICS code is 237310, with a size standard of $45 million average annual receipts. The solicitation closes on August 23, 2024, at 10:00 am EDT.
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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 at least three (3) suppliers that you do business with, to include points of contact and phone numbers.
I. Name of Supplier: _____________________________________________________
Address: ______________________________________________________________
Name of POC: _________________________________________________________
Telephone No: _________________________________________________________
II. Name of Supplier: ____________________________________________________
Address: ______________________________________________________________
Telephone No: _________________________________________________________
III. Name of Supplier: ___________________________________________________
Address: ______________________________________________________________
Telephone No: ________________________________________________
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: __________________________________________________________ Email: __________________________________________________________
INSTITUTION NAME: __________________________________________________________
POC name: __________________________________________________________________ POC title: _________________________________________________________________ POC phone number: ______________________ fax number: _______________________ Email: __________________________________________________________
I give permission for the following information regarding my account/s at your institution to be released to representatives of the 910th Contracting Squadron, Youngstown ARS, Vienna OH.
| _____________________________________ | ________________________________ | |
| 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 |
LIST OF EQUIPMENT DEDICATED TO PROJECT
(Owned/Rented)
1.
2.
3.
4.
5.
Attachment 4
File details come from the government source that posted it. Updated .