Attachment 7 - Financial Disclosure - 515-24-500.doc
DOC document 118 KB Posted
- Attached to
- Z1DA--Battle Creek JOC IDIQ 515-24-500
- Solicitation number
- 36C25025R0070
About this file
This document is a Financial Disclosure form for a VA Job Order Contract (JOC) Indefinite Delivery Indefinite Quantity (IDIQ) solicitation. The solicitation (Number 36C25025R0070) is for the Battle Creek VA Medical Center in Michigan, issued by the Department of Veterans Affairs Veterans Health Administration Network Contracting Office 10. The form requires prospective contractors to provide detailed financial information from their banking institution, including account details, credit ratings, line of credit status, average balance, and banking relationship history. Financial institutions are instructed to complete the questionnaire and email it to a VA contracting officer, with the information being treated as Source Selection Sensitive under Federal Acquisition Regulation guidelines.
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Text version
FOR OFFICIAL USE ONLY
Source Selection Sensitive Information—See FAR 2.101 & 3.104 Indefinite Delivery Indefinite Quantity - Job Order Contract (JOC) Solicitation#: 36C25025R0070
FINANCIAL QUESTIONNAIRE
OFFEROR INSTRUCTIONS: Please complete below and return as per instructions below
Prospective Contractor for which information is being requested:
Firm Name:
Address:
Point of Contact:
Phone Number:
Name & Signature of the Person Authorized to request financial information:
Please complete below and return as per instructions no later than:
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FINANCIAL INSTITUTION INSTRUCTIONS: The Department of Veterans affairs, Network Contracting Office 10 is considering the firm listed below for award of a VA contract. In order to be responsive to VA’s needs, it is requested that you complete this questionnaire and email to (terrance.deininger@va.gov). Your comments are considered Source Selection Sensitive; therefore, you are advised that the Federal Acquisition Regulation (15.506) prohibits the release of the names of individuals providing reference information about Offeror’s financial status.
Banking Institution:
| Account number: | Type of account: | Average balance: | Do they have a Line of Credit [ ] Yes [ ] No | |
| What is their limitation: | Unused Balance: | Relationship with the bank: [ ] Outstanding [ ] Satisfactory [ ] Other: | How long have they been a client: | |
| What is their most recent credit rating: | Date of most recent credit rating: | Credit rating prepared by: |
Signature of Provider:
Title: Date:
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File details come from the government source that posted it. Updated .