Attachment_12_Contractor_Responsibility_Letter.pdf

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 Rachel Italiano and/or Barry Jundt 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