Financial Questionnaire Sheet.pdf
PDF 152 KB Posted
- Attached to
- Boiler Maintenance
- Solicitation number
- FA452827QAS002
About this file
This document is a Responsibility Questionnaire and Financial Institution Reference Sheet for federal contract solicitation FA4528-26-Q-TA50 issued by the 5th Contracting Squadron at Minot Air Force Base, North Dakota.
The Responsibility Questionnaire requires contractors to provide information on up to three previous customers or contracts to demonstrate company capability and reliability. For each reference, contractors must supply the customer/contract name, address, point of contact name and telephone number, dates/years of performance, annual dollar value, and a description of services performed with additional comments. The Financial Institution Reference Sheet requires contractors to identify each financial institution where the company maintains a business account and provide contact information for a point of contact at that institution. Contractors authorize the release of account information to the 5th Contracting Squadron for responsibility evaluation purposes. If selected as the potential awardee, the form will be sent to the financial institution for completion, requesting information provided as ranges, including average monthly checking and savings balances, current loan amounts, lines of credit, payment history, length of relationship with the institution, and credit rating. Both forms are to be submitted with the proposal as part of the contractor responsibility determination process for award evaluation.
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Text version
FA4528-26-Q-TA50
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 up to three (3) customers/contracts that you have held or done business with, to include points of contact and phone numbers.
I. Name of Customer/Contract:
Address:
Name of POC:
Telephone No:
Dates/Years of Performance:
Annual $ Value:
Services Performed/Additional Comments:
II. Name of Customer/Contract:
III. Name of Customer/Contract:
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:
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 5 th Contracting Squadron, Minot AFB, North Dakota.
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
File details come from the government source that posted it. Updated .