4._Financial_Institution_Reference_Sheet.pdf

FA4659-14-R-0014

Attachment 4

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

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