Atch_4-Financial_Institution_Reference_Sheet.pdf

Attachment 4

FA4659-16-R-0006

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

You may return this form to SSgt Justin Baker electonically at justin.baker.19@us.af.mil or by fax at 701-747-4215.