Att4_Financial_Institution_Reference_Sheet.pdf

Source Selection Information -- See FAR 2.101 and 3.104 – FOR OFFICIAL USE ONLY

Source Selection Information -- See FAR 2.101 and 3.104 – FOR OFFICIAL USE ONLY

FINANCIAL INSTITUTION REFERENCE SHEET

Instructions to Contractor: 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 institutions in regards to a determination of contractor responsibility as part of the evaluation for the solicitation: FA465919RA003, for Energy Management Control Systems (EMCS) Services at Grand Forks AFB, ND. The top portion should be completed first, then sent to each financial institution for completion. Please have completed surveys returned directly from the financial institutions to Mr. Ja’Haun Stafford via email at jahaun.stafford.2@us.af.mil

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