FA465915R0015_Financial_Institution_Reference_Sheet.pdf

FA4659-15-R-0015

Attachment 6

FINANCIAL INSTITUTION REFERENCE SHEET

Instructions to Contractor: Please fill out a reference sheet for each financial institution that you have a business acount 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 the execution of award for the Grand Forks AFB, ND Repair HVAC Controls and Equipment, Bldg 607, FA4659-15-R-

0015.

TO BE FILLED OUT BY CONTRACTOR:

COMPANY’S NAME:_____________________________________________________

Point of Contact (POC) Name:_______________________________________________

POC Phone Number:_______________________________________________________

INSTITUTION NAME:____________________________________________________

Acct Number:_________________________2 nd

Acct Number:_____________________

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 319 th Contracting Squadron, Grand Forks AFB, North Dakota.

Name/Title Signature Date

DO NOT HAVE THIS SECTION FILLED OUT. THIS SECTION TO BE FILLED OUT

BY FINANCIAL INSTITUTION.

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 saving:__________________________

Amount of any current loans:_______________________________

Amount of any lines of credit:_______________________________

Any late payment or NSF’s:_________________________________________________

How long with institution:_______________________

Credit rating with this institution:______________________

I verify the information provided above is current as of:___________________

Name/Title Signature Date

PLEASE FAX COMPLETED SHEET TO: A1C Irinieta Tabuyaqona 701-747-4215