Attachment 4 - Financial Questionnaire Sheet.pdf
PDF 357 KB Posted
- Attached to
- Hoods and Ducts Cleaning Federal contract opportunity
- Solicitation number
- FA452820QRO02
About this file
This document contains a financial questionnaire sheet and related federal contract opportunity solicitation for hoods and ducts cleaning services. The financial questionnaire sheet requests contact information for up to three past customers or contracts, including points of contact, phone numbers, annual value, dates of performance, and services performed. It also includes a financial institution reference sheet to provide banking information such as average account balances, loans, lines of credit, and credit ratings to aid in evaluating contractor responsibility.
The related federal contract opportunity solicitation is from the Department of the Air Force Global Strike Command to provide all personnel, equipment, tools, materials, vehicles, supervision and services necessary to clean exhaust hoods, adjoining ducts and all equipment related to exhaust systems at Minot Air Force Base and fifteen surrounding missile alert facilities. The contractor must perform to standards in the contract as well as all applicable federal, state and local regulations and commercial standards, and follow the cleaning schedule in the performance work statement appendix.
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Other files for this federal contract opportunity
| File | Type | Posted |
|---|---|---|
| Attachment 5 - Past Performance Questionaire.pdf | ||
| Attachment 6 - Combo.pdf | ||
| Attachment 3 - Quote Sheet.xlsx | XLSX spreadsheet | |
| Attachment 1 - PWS Revised 21 May 2019.pdf | ||
| Attachment 2 - SCA WD.pdf |
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Text version
FA4528-20-Q-RO02
Attachment 4
RESPONSIBILITY QUESTIONNAIRE
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:____________________________________________
Address: ______________________________________________________________
Name of POC: _________________________________________________________
Telephone No: _________________________________________________________
Dates/Years of Performance: ______________________________________________
Annual $ Value: ________________________________________________________
Services Performed/Additional Comments: ___________________________________
FA4528-19-Q-LB05
Attachment 3 Page 2
III. Name of Customer/Contract:___________________________________________
Address: ______________________________________________________________
Name of POC: _________________________________________________________
Telephone No: ________________________________________________
Dates/Years of Performance: ______________________________________________
Annual $ Value: ________________________________________________________
Services Performed/Additional Comments: ___________________________________
FA4528-19-Q-LB05
Attachment 3 Page 3
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 5 th
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
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