Attachment 4 - Financial Questionnaire.pdf

FA4528-25-Q-TA01

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 or Email:

Dates/Years of Performance:

Annual $ Value:

Services Performed/Additional Comments:

II. Name of Customer/Contract:

Address:

Name of POC:

Telephone or Email:

Dates/Years of Performance:

Annual $ Value:

Services Performed/Additional Comments:

III. Name of Customer/Contract:

Address:

Name of POC:

Telephone or Email:

Dates/Years of Performance:

Annual $ Value:

Services Performed/Additional Comments:

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: Email:

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