Attachment 5 - Financial Institution Reference Sheet.pdf
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- Attached to
- Repair HVAC Bldg 91259 Hurlburt Field
- Solicitation number
- FA441724B0002
About this file
The document provided is an Attachment 5 - Financial Institution Reference Sheet. It is a form that must be included in a contractor's proposal, which will then be sent to the contractor's banking institution to provide financial information. The required information includes the average monthly balances in checking and savings accounts, amounts of any current loans or lines of credit, whether there have been any late payments or non-sufficient funds issues, the length of time the contractor has been with the institution, and the contractor's credit rating with the institution. The form is part of the evaluation for award of solicitation FA4417-24-R-0004 for the repair of the HVAC system in Building 91259 at Hurlburt Field, which is being issued by the Department of the Air Force Special Operations Command.
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FOR OFFICIAL USE ONLY
SOURCE SELECTION SENSITIVE – SEE FAR 3.104
FA4417-24-R-0004
FOR OFFICIAL USE ONLY
SOURCE SELECTION SENSITIVE – SEE FAR 3.104
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 1 SOCONS (Contracting Squadron), Hurlburt Field FL)
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
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