Exhibit 3 Responsibility Questionnaire.doc

FA4528-11-R-0001

EXHIBIT 3

RESPONSIBILITY QUESTIONAIRE

The following information is needed to help evaluate and determine your company responsible. Please complete the following items and submit with your proposal:

a. The names of at least three (3) suppliers that you do business with, to include points of contact and phone numbers.

I. Name of Supplier: _____________________________________________________

Address: ______________________________________________________________

Name of POC: _________________________________________________________

Telephone No: _________________________________________________________

II. Name of Supplier: ____________________________________________________

Telephone No: _________________________________________________________

III. Name of Supplier: ___________________________________________________

Telephone No: ________________________________________________

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 financial 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 Phone Number: __________________ FAX Number: __________________

I give permission for the following information regarding my account(s) at your institution to be released to representatives of the 5th Contracting Squadron, Minot AFB, North Dakota.

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 LISTED ABOVE FOR COMPLETION.

TO BE COMPLETED 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 the information provide above is current as of ______________.

Name/Title

Signature/Date