Financial_Institution_Ref_Sheet.pdf

FINANCIAL INSTITUTION REFERENCE SHEET (FA4659-17-R-0003)

Instructions to Contractor: Forward this 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 to exercise the option year of this contract.

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 319 th

Contracting Flight, Grand Forks AFB, North Dakota.

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 or NSF’s: ______________________________________________________________

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

Fax or Email Reference Sheet to TSgt Jonathon Zolnai (jonathon.zolnai@us.af.mil) Contract Specialist

Fax: 701-747-4215