Attachment_05-Financial_Reference_Sheet.docx

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 Anthony Parsons of the 19th Contracting Squadron, Little Rock AFB, Arkansas.

Name/Title Signature/Date DO NOT HAVE THIS SECTION FILLED OUT. 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

Attachment 5