Attachment_4_Contractor_Financial_Reference_Sheet.pdf

RFP FA4460-13-R-0001

Attachment 4 Page 1 of 1

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 Calvin Hickman and/or Ms. Brenda G. Tate of the 19th 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