Financial Responsibility .pdf
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This document is a Financial Institution Reference Sheet (FA5004-26-B0001) issued by the 354th Contracting Squadron at Eielson Air Force Base in Alaska. The form is designed to help evaluate a contractor's financial responsibility and ability to perform a contract, as required by Federal Acquisition Regulation (FAR) 9.104-1(a). The document requires two-part completion: first by the contractor, who provides company and point of contact information and grants permission to release financial details, and second by the financial institution, which must provide confidential financial information such as average account balances, loan amounts, lines of credit, payment history, and credit rating.
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FA5004-26-B0001
FINANCIAL INSTITUTION REFERENCE SHEET
Instruction to Contractor: IAW FAR 9.104-1(a) to be determined responsible, a contractor must have the adequate resources to perform the contract or the ability to attain them. This sheet may be sent to the banking institutions in regards to a determination of contractor responsibility as part of the evaluation for exercise of this option period.
Please complete the form and send it to each financial institution that you have a business account with.
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:_____________________________________
POC Email address:______________________________________
I give permission for the following information regarding my account(s) at your institution to be released to representatives of the 354th Contracting Squadron, Eielson AFB, AK.
Name/Title Signature/Date
TO BE FILLED OUT BY FINANCIAL INSTITUTION:
Please give amounts as a range – i.e. low four figures, mid six figures, ect.
Average monthly balance in checking:____________________________
Average monthly balance in savings:_____________________________
Amount of any current loans:____________________________________
Amounts 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 __MM/DD/YYYY__.
Name/Title Signature/Date
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