Attachment E - Financial References Questionnaire.pdf

54 KB Posted

Attached to
FUSRAP/HTRW Verification & Laboratory Services
Solicitation number
W912P923R0009
Issued by

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This document contains a financial references questionnaire to be filled out by contractors bidding on the solicitation for FUSRAP/HTRW Verification & Laboratory Services. The solicitation is being conducted by the Department of the Army Corps of Engineers Engineering District St Louis. The financial references questionnaire requests information from the contractor's financial institutions regarding average monthly balances in checking and savings accounts, any outstanding loans and payment history, credit limits, the institution's assessment of the contractor as a responsible customer, and any late payments or non-sufficient funds issues. The financial institution is asked to verify the provided information and sign and date the completed form.

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Financial References Questionnaire

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 Angie Grimes, Contract Specialist of the USACE-St. Louis District, Missouri.

Name/Title Signature/Date

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: _______________________________ Are there any outstanding loans: Yes/No Are payments on time: Yes/No Credit limit: _____________________________________ Are they a responsible customer: Yes/No Any late payments or NSF’s: _____________________________________ How long with this institution: _____________________________________ Credit rating with this institution: _____________________________________

Comments: ______________________________________________________________

I verify that the information provided above is current as of _____________________

Name/Title Signature/Date

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