Atch5_FinancialForm.pdf

DEPARTMENT OF THE AIR FORCE

99TH CONTRACTING SQUADRON (ACC)

NELLIS AIR FORCE BASE, NEVADA

Global Power for America

13 August 2010

MEMORANDUM FOR WHOM IT MAY CONCERN

FROM: 99 CONS/LGCA

5865 Swaab Blvd, Bldg 588 Nellis AFB NV 89191-7063

SUBJECT: Financial Information Request and Release Authorization – Attachment #5

REFERENCES: (a) Solicitation FA4861-10-B-A029

(b) Repair Data Lab & FTI, Building 423

1. Our office is evaluating

(NAME OF FIRM)

of

(FIRM’S ADDRESS, INCLUDING CITY, STATE, AND ZIP CODE)

for possible award of referenced contract. In order to proceed, we must verify the contractor’s financial capability. The firm has provided your name as their bank reference and granted you release, as indicated below, to provide it to the government.

2. Please complete the attached questionnaire and return it by fax (702-652-2532) or email to me (richard.jedlinski@nellis.af.mil) at your earliest convenience, but not later than seven (7) calendar days after receipt of this request.

3. All information provided will be FOR OFFICIAL USE ONLY and will not be publicly released. If you need any other information or have any questions, please call me at 702-652-9121. Thank you very much for your assistance.

JACQUELYN E. BUKY

Contracting Officer Attachment Financial Information Sheet

1st Ind, (Name of Offeror’s Firm) (Date)

TO:

(Name of Financial Institution) (Phone # w/Area Code)

I hereby authorize the financial institution to release my information as requested.

SIGNATURE:

BY:

(Print name/title of authorized representative)

Attachment 1

RESPONSIBILITY QUESTIONNAIRE - FINANCIAL

FA4861-10-B-A029

REPAIR DATA LAB & FTI, BUILDING 423

1. Name of Contractor to whom the following information is applicable:

2. Name of Financial Institution:

3. Address of Financial Institution:

4. How long has the firm been a commercial customer of your bank?

5. What is the type of account and its average* balance? (continue on separate sheet if necessary) Checking $ Checking $ Savings $ Savings $

CD $ CD $

Money Market $ Money Market $ Other $

(SPECIFY TYPE)

6. Does the company maintain a loan balance at the bank? In what amount?

YES NO $

7. Does the company maintain an unsecured line of credit at the bank? In what amount?

YES NO $

8. What company’s standing with your bank?

Outstanding Excellent Satisfactory Poor Unsatisfactory Other Explain on separate sheet of paper

9. COMMENTS:

I certify that the above information is correct and current as of

(DATE)

SIGNATURE:

BY:

(Print name/title of authorized representative)

DATE: