Attachment_4_-_Financial_Responsibility.docx

Attachment 4

FA4528-17-R-0028

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: ___________________________ Account #_______________________________

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.

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 ____________.