FINANCIAL RESPONSIBILITY.doc

DETERMINATION OF FINANCIAL RESPONSIBILITY

QUESTIONNAIRE

To assist the government in determining bidder responsibility the government needs:

1. General financial organizational data.

2. Organizational chart identifying the company officers.

3. Information on five (5) of the most recent and relevant contracts that the bidder is presently performing or has completed.

Information must address the type of acquisition identified in the solicitation.

All Department of Defense contracts are preferred; however, if the bidder does not have such experience then municipal services, then public services may be listed.

The bidder must contact all representatives of the companies listed below and advise them that the NAS JRB Fort Worth Contracting Office will be contacting them to confirm information submitted by the bidder.

BIDDER’S ORGANIZATIONAL DATA

Company Name:

Date company organized:

Dates of company’s fiscal year :

Organizational Chart:

Note: Attach to this questionnaire.

FINANCIAL DATA

Federal Income Tax #:

Bank name:

Address:

Telephone:

Point of contract:

CERTIFICATION

Information that is provided on and with this questionnaire is accurate and correct to the best of my knowledge.

Date signature

Printed Name/Title:__________________________

RELEVANT GOVERNMENTCONTRACT DATA

I. Government Installation/Company: ______________________________________________

Address:

Telephone:

Point of contact:

Description of Services: ______________________________________________________

Contract Number:

Performance Period: _________________________________________________________

Total cost of contract: ____________________________________________________

Was your company a Prime or Subcontractor? ___________________________________

II. Government Installation/Company: ______________________________________________

Address:

Telephone:

Point of contact:

Description of Services: ______________________________________________________

Contract Number:

Performance Period: _________________________________________________________

Total cost of contract: ____________________________________________________

Was your company a Prime or Subcontractor? ___________________________________

II. Government Installation/Company: ______________________________________________

Address:

Telephone:

Point of contact:

Description of Services: ______________________________________________________

Contract Number:

Performance Period: _________________________________________________________

Total cost of contract: ____________________________________________________

Was your company a Prime or Subcontractor? ___________________________________

III. Government Installation/Company: ______________________________________________

Address:

Telephone:

Point of contact:

Description of Services: ______________________________________________________

Contract Number:

Performance Period: _________________________________________________________

Total cost of contract: ____________________________________________________

Was your company a Prime or Subcontractor? ___________________________________

IV. Government Installation/Company: ______________________________________________

Address:

Telephone:

Point of contact:

Description of Services: ______________________________________________________

Contract Number:

Performance Period: _________________________________________________________

Total cost of contract: ____________________________________________________

Was your company a Prime or Subcontractor? ___________________________________

V. Government Installation/Company: ______________________________________________

Address:

Telephone:

Point of contact:

Description of Services: ______________________________________________________

Contract Number:

Performance Period: _________________________________________________________

Total cost of contract: ____________________________________________________

Was your company a Prime or Subcontractor? ___________________________________

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Attachment 4

FA6675-12-R-0011