J10 Financial Institution Reference Sheet.docx
DOCX document 17 KB Posted
- Attached to
- Replace Heating Plant
- Solicitation number
- 75H70122R00036
About this file
This document contains a financial institution reference sheet for contractors bidding on a federal contract opportunity with the Indian Health Service. The opportunity is to replace the heating plant at the Pine Ridge Hospital in Pine Ridge, South Dakota. Contractors are required to fill out and return the reference sheet for each financial institution they have a business account with in order for the agency to verify the contractor's financial responsibility as part of the evaluation process. The sheet requests information such as average monthly balances, amounts of any current loans or lines of credit, credit ratings, and history with the institution. Completed sheets must be returned to the listed point of contact at the Indian Health Service by the specified due date.
View the file
Other files
Show all 19
On GovTribe
Work with this file
- Download the original file
- Contacts named in this file
- Similar government files
- Ask GovTribe AI about this file
Text version
Attachment J10
FINANCIAL INSTITUTION REFERENCE SHEET
75H701-22-R-00036
Instructions to Offerors: Please fill out and return 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 of offers for contract award.
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: ______________
I give permission for the following information regarding my account(s) at your institution to be released to the Contracting Officer at the Indian Health Service – Division of Engineering Services – Seattle.
Printed 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, 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 of NSFs: ____________________________________ 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 |
You may return this form to Matt Sanders at matt.sanders@ihs.gov.
File details come from the government source that posted it. Updated .