FINANCIAL_INSTITUTION_REFERENCE_SHEET.pdf
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- Attached to
- Repair 69 MXS Mission Areas Bldg 607
- Solicitation number
- FA4659-16-R-0004
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Attachment 5 - Financial Institution Reference Sheet
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FA4659-16-R-0004
Attachment 5
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 69 MXS Mission Areas Bldg 607 FA4659-16-R-0004.
TO BE FILLED OUT BY CONTRACTOR:
COMPANY’S NAME:_____________________________________________________
Point of Contact (POC) Name:_______________________________________________ POC Phone Number:_______________________________________________________
INSTITUTION NAME:____________________________________________________
Acct Number:_________________________2nd 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 319th Contracting Flight, 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: TSgt David Sanders 701-747-4215 or email to david.sanders.15@us.af.mil mailto:david.sanders.15@us.af.mil
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