Atch_4_-_Finacial_Info_Request_-_14-R-0004.pdf

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 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 90P th P Contracting Squadron, F.E. Warren AFB, Wyoming.

Name/Title Signature/Date

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

Maintain Base Pavements F.E. Warren AFB, Wyoming

FA4613-14-R-0004

Attachment 4 - Financial Information Request