Financial Institution Reference Sheet.doc

FINANCIAL INSTITUTION REFERENCE SHEET

Instructions to Contractor: 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 for solicitation number FA4659-12-R-0013, Repair Sanitary Sewer Lagoon-South Secondary JGAR200345, Grand Forks AFB ND.

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

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 _____________________________

Name/Title

Signature/Date