B01 Attachment 08 - Financial Institution Reference Sheet.pdf
PDF 366 KB Posted
- Attached to
- Zuni Wastewater Treatment Improvements
- Solicitation number
- 75H70120R00029
About this file
This document contains a financial institution reference sheet and details of a federal contract solicitation. The financial institution reference sheet requests average account balances, credit ratings, and loan details from a contractor's financial institutions to aid in a responsibility determination in accordance with FAR Part 9.104-1.
The federal contract solicitation is for the Zuni Wastewater Treatment Improvements project issued by the Department of Health and Human Services Indian Health Service. The contractor shall furnish all labor, materials, and equipment to renovate and expand the existing 32.6-acre, six cell lagoon facility to a 49-acre, five cell treatment system through a two-phase construction approach. This acquisition is set aside for Indian Small Business Economic Enterprises in accordance with the Buy Indian Act.
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Text version
FINANCIAL INSTITUTION REFERENCE SHEET
Instructions to Contractor: Forward this 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 in accordance with FAR Part 9.104-1.
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 Indian Health Service, Department of Engineering Services, Seattle, WA.
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: _________________
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
Email Reference Sheet to Mr. Matt Sanders(matt.sanders@ihs.gov)
Contracting Officer
Solicitation 75H70120R00029 Zuni Wastewater Treatment Improvements
File details come from the government source that posted it. Updated .