DRAFT Attachment 4 - Financial Information Request_template.pdf

MEMORANDUM FOR WHOM IT MAY CONCERN

FROM: 766 ESS/PKI

560 Central Av (Bldg 287), Joint Base Pearl Harbor-Hickam 96860-4961

SUBJECT: Financial Information Request and Release Authorization

REFERENCES: (a) Solicitation FA521521B0001

(b) Guam and Hawaiian Islands Simplified Acquisition Base Engineering Requirement (SABER)

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 include in your Invitation For Bid submission NLT the specified date in the solicitation.

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 email the undersigned at christian.freire@us.af.mil. Thank you very much for your assistance.

FREIRE CHRISTIANS

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)

RESPONSIBILITY QUESTIONNAIRE - FINANCIAL

FA521521B0001

GUAM AND HAWAII SIMPLIFIED ACQUISITION BASE ENGINEER REQUIREMENT (SABER)

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: