Attachment_9_Financial_Instituition_Reference_Sheet.docx

FA4460-17-R-0004

Financial Institution Reference Sheet

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 Nicholas Evans 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

Attachment 9