Attachment_11_-_Financial_Responsibility_Questionnaire.doc

FA0021-15-R-0004

Attachment 11

18 March 2015

FA0021-15-R-0004

Attachment 11

18 March 2015

FINANCIAL RESPONSIBILTY QUESTIONNAIRE

SUSPENSE: 14 May 2015 @ 1400hrs CST Contractor Information:

Name:

Address:

Point Of Contact (POC): ________________________________________________________________ Phone:

Financial Institution:

The above named contractor is currently performing services for HQ AFSOC at Hurlburt Field, FL. As part of the financial responsibility determination required by FAR 9.104-1, please complete the following and return this form to: Kurt Buchanan, email kurt.buchanan.1@us.af.mil or Maria Jaine A. Sipin, email at maria_jaine.sipin@us.af.mil, not later than 14 May 2015/ 1400hrs CST.

If you have any questions, please call me (850)884-3196. Your assistance is appreciated.

Institution Name:

Address:

POC:

Title:

Phone:

Fax:

1. How long has the account(s) been open?____________________________________________

2. What is the average balance in the account?______________________________ (ex: high 6 figure, low 8 figure etc.)

3. Does the customer have a credit line available?_______________________________________ If so, what amount of credit is available?________________________________ (ex: high 6 figure, low 7 figure, etc.)

4. Is the customer in good standing?______________________________________

5. Does the institution feel comfortable continuing to support this customer in their business endeavors:_____________________________________________________________________

6. Additional remarks, if any:________________________________________________________ Signature:_____________________________ Date:___________________