Attachment_4_-_Financial_Responsibility_Questionnaire.docx

FA0021-16-R-0040

Attachment 4 7 September 2016

FA0021-16-R-0040

Attachment 4 7 September 2016

FINANCIAL RESPONSIBILTY QUESTIONNAIRE

SUSPENSE: 26 October 2016 @ 1400hrs CST

Contractor Information:

Name: _______________________________________________________________________________

Address: _______________________________________________________________________________

Point Of Contact (POC): ________________________________________________________________

Phone: ______________________________________________________________________________

Financial Institution:

The above named contractor is proposing to perform 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: Maria Jaine A. Sipin at maria_jaine.sipin@us.af.mil, or Lauren K. Sydnor at lauren.sydnor.1@us.af.mil not later than 26 October 2016/ 1400hrs CST.

If you have any questions, please call me (850)884-7829. 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:___________________