FINANCIAL INSTITUTION REFERENCE SHEET.docx

FA4659-11-R-0016

FINANCIAL INSTITUTION REFERENCE SHEET

Instructions to Offerors: Please fill out and return 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 of offers for contract award.

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 319th Contracting Flight, Grand Forks AFB ND.

Printed 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.

PLEASE FAX COMPLETED FORM TO: JEREMIAH SNEDKER, 701-747-4215

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 of NSFs: ____________________________________ How long with this institution: __________________________________ Credit rating with this institution: ________________________________

I verify that the information provided above is current as of _____________________________

Attachment 6