Attachment_5_RESPONSIBILITY.pdf

Solicitation No: FA4460-10-R-0018

Attachment 5

FINANCIAL INSTITUTION REFERENCE SHEET

Instructions to Contractor: Include with your proposal a 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 as part of the evaluation for award of this solicitation.

TO BE FILLED OUT BY CONTRACTOR:

COMPANY’S NAME: ____________________________________________________________

Point of Contact (POC) Name: ______________________________________________________

POC Phone Number: ______________________________________________________________

INSTITUTION NAME: ___________________________________________________________

POC name: _____________________________________________________________________

POC title: ______________________________________________________________________

POC email address: ______________________________________________________________

POC phone number: ______________________ fax number: ___________________________

I give permission for the following information regarding my account/s at your institution to be released to 1Lt

Keith Harbeson or Barry Jundt of the 19 th

Contracting Squadron, Little Rock AFB, Arkansas.

Name/Title Signature/Date

DO NOT HAVE THIS SECTION FILLED OUT. IF YOUR FIRM IS SELECTED AS THE POTENTIAL

AWARDEE, THIS FORM WILL BE SENT TO YOUR BANKING INSTITUTION FOR COMPLETION.

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