Attachment 6 Financial Institution Reference Sheet.pdf

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Attached to
Medical Surveillance
Solicitation number
FA670325Q0006
Issued by

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The Financial Institution Reference Sheet is a form used in the Medical Surveillance solicitation (FA670325Q0006) to evaluate a potential contractor's financial responsibility. The document requires offerors to complete detailed financial information from their banking institutions, including average monthly balances, current loans, lines of credit, and credit ratings. The form must be fully completed and submitted to the 94th Contracting Flight at Dobbins Air Reserve Base, with the purpose of determining the contractor's financial capability to perform the medical surveillance services. Failure to complete the form may render the quote ineligible for award. The solicitation allows offerors to include additional financial documentation such as banking statements or financial reports to support their application.

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FINANCIAL INSTITUTION REFERENCE SHEET

Instruc ons to Offeror: Complete and return a reference sheet for each financial ins tu on that you have a business account with. The Offeror is responsible to send this sheet to their banking ins tu on(s) in regards to a determina on of Contractor Responsibility in accordance with FAR 9.104-1, General Standards.

This sheet will be used to evaluate your ability to meet the necessary financial informa on required by this solicita on located at Dobbins ARB, GA. Failure to complete this sheet may render your quote ineligible for award.

NOTE: Offeror must complete this form in its en rety. Offerors may include addi onal informa on i.e. a copy of their latest Financial Report or Banking Statements (Current or previous year).

COMPLETED BY THE OFFEROR

Company’s Name:

Point of Contact (POC) Name:

POC Phone Number:

INSTITUTION’S NAME:

POC Name:

POC Title:

POC Phone Number: Fax Number:

I give permission for the following informa on regarding my account(s) at your ins tu on to be released to representa ves of the 94th Contrac ng Flight, 1538 Atlan c Ave. Bldg. 812, Dobbins ARB, GA 30069-4900.

Print Name / Title Signature Date

COMPLETED BY FINANCIAL INSTITUTION:

Request amount 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 of NSFs:

How long with this ins tu on:

Credit ra ng with this ins tu on:

I verify that the informa on provided above is current as of

Name / Title Signature

21 April 2025

FA670325Q0006

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File details come from the government source that posted it. Updated .