Attachment 6 - Financial.pdf

FINANCIAL INSTITUTION REFERENCE SHEET

Attachment 6

FA4528-21-R-0008

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: __________ _ Account# ____________ _

I give permission for the following information regarding my account/s at your institution to be released to representatives of the 5111 Contracting Squadron, Minot AFB, North Dakota.

Name/fitle Signature/Date

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

A WARD EE, 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 /011r figures, mid six figures, etc.

Average monthly balance in checking:-------

Average monthly balance in savings:-------

Amount of any current Joans:------

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/fitle Signature/Date