Attach_1_Responsibility_Questionnaire.doc

FA4528-13-R-0022

Attachment 1

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 up to three (3) customers/contracts that you have held or done business with, to include points of contact and phone numbers.

I. Name of Customer/Contract:_____________________________________________

Address: ______________________________________________________________

Name of POC: _________________________________________________________

Telephone No: _________________________________________________________

Dates/Years of Performance: ______________________________________________

Annual $ Value: ________________________________________________________

Services Performed/Additional Comments: ___________________________________

II. Name of Customer/Contract:____________________________________________

Telephone No: _________________________________________________________

III. Name of Customer/Contract:___________________________________________

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 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 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 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