A15 Attachment 4 Responsibility Questionnaire Renovate Hangar 295.docx
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- Attached to
- Renovate Hangar B295
- Solicitation number
- FA665624B0001
About this file
This document is an Attachment 4 Responsibility Questionnaire for the federal contract opportunity to Renovate Hangar 295. The questionnaire collects information to evaluate the responsibility of the contractor, including supplier references, financial institution references, and a list of equipment dedicated to the project. The related federal contract opportunity is a solicitation for renovating Hangar B295 at the 910th Airlift Wing in Youngstown, Ohio. The project consists of removing the concrete mezzanine, relocating HVAC, piping, and electrical systems, and constructing new stairs and a catwalk. The contract is a single-award, firm-fixed price acquisition set aside for HUBZone small businesses. The estimated project value is between $500,000 and $1,000,000, with a 240-calendar day performance period. The solicitation will be posted on SAM.gov, and interested parties should register on the Interested Vendors List.
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ATTACHMENT 4
RESPONSIBILITY QUESTIONNAIRE
The following information is needed to help evaluate and determine your company responsible. Please complete the following items and submit with your proposal:
A. The names of at least three (3) suppliers that you do business with, to include points of contact and phone numbers.
I. Name of Supplier: _____________________________________________________
Address: ______________________________________________________________
Name of POC: _________________________________________________________
Telephone No: _________________________________________________________
II. Name of Supplier: ____________________________________________________
Address: ______________________________________________________________
Telephone No: _________________________________________________________
III. Name of Supplier: ___________________________________________________
Address: ______________________________________________________________
Telephone No: ________________________________________________
FINANCIAL INSTITUTION REFERENCE SHEET
Instructions to Contractor: Include with your proposal 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 for award of this solicitation.
TO BE FILLED OUT BY CONTRACTOR:
COMPANY’S NAME: ____________________________________________________________
Point of Contact (POC) Name: _______________________________________________ POC Phone Number: __________________________________________________________ Email: __________________________________________________________
INSTITUTION NAME: __________________________________________________________
POC name: __________________________________________________________________ POC title: _________________________________________________________________ POC phone number: ______________________ fax number: _______________________ Email: __________________________________________________________
I give permission for the following information regarding my account/s at your institution to be released to representatives of the 910th Contracting Squadron, Youngstown ARS, Vienna OH.
| _____________________________________ | ________________________________ | |
| Name/Title | Signature/Date |
DO NOT HAVE THIS SECTION FILLED OUT. IF YOUR FIRM IS SELECTED AS THE POTENTIAL AWARDEE, THIS FORM WILL BE SENT TO YOUR BANKING INSTITUTION FOR COMPLETION.
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 |
LIST OF EQUIPMENT DEDICATED TO PROJECT
(Owned/Rented)
1.
2.
3.
4.
5.
FA665624B0001 Attachment 4
File details come from the government source that posted it. Updated .